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Charest-Morin R, Flexman AM, Srinivas S, Fisher CG, Street JT, Boyd MC, Ailon T, Dvorak MF, Kwon BK, Paquette SJ, Dea N. Perioperative adverse events following surgery for primary bone tumors of the spine and en bloc resection for metastases. J Neurosurg Spine 2019; 32:98-105. [PMID: 31561231 DOI: 10.3171/2019.6.spine19587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/28/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Surgical treatment of primary bone tumors of the spine and en bloc resection for isolated metastases are complex and challenging. Operative care is fraught with complications, though the true incidence and predictors of adverse events (AEs), length of stay (LOS), and mortality in this population remain poorly understood. The primary objective of this study was to describe the incidence and predictors of perioperative AEs in these patients. Secondary objectives included the determination of the incidence and predictors of admission to the intensive care unit (ICU), unanticipated reoperation during the same admission, hospital LOS, and mortality. METHODS In this retrospective analysis of prospectively collected data, the authors included consecutive patients at a single quaternary care referral center (January 1, 2009, to September 30, 2018) who underwent either surgery for a primary bone tumor of the spine or an en bloc resection for an isolated spinal metastasis. Information on perioperative AEs, demographic data, primary tumor histology, neurological status, surgical variables, pathological margins, Enneking appropriateness, LOS, ICU stay, reoperation during the same admission period, and in-hospital mortality was collected prospectively in the institutional database. The modified frailty score was extracted retrospectively. RESULTS One hundred thirteen patients met the inclusion criteria: 98 with primary bone tumors and 15 with isolated metastases. The cohort was 59% male, and the mean age was 49 years (SD 19 years). Overall, 79% of the patients experienced at least 1 AE. The median number of AEs per patient was 2 (IQR 0-4 AEs), and the median LOS was 16 days (IQR 9-32 days). No in-hospital deaths occurred in the cohort. Thirty-two patients (28%) required an ICU stay and 19% underwent an unanticipated second surgery during their admission. A longer surgical duration was associated with a higher likelihood of AEs (OR 1.21/hour, 95% CI 1.06-1.37, p = 0.005), longer ICU stay (OR 1.35/hour, 95% CI 1 1.20-1.52, p < 0.001), and reoperation (OR 1.001/hour, 95% CI 1.0003-1.003, p = 0.012). Longer hospital LOS was independently predicted by older age, female sex, upper cervical and sacral location of the tumor, surgical duration, preoperative neurological deficit, presence of AEs, and higher modified frailty index score. CONCLUSIONS Surgeries for primary bone tumors and en bloc resection for metastatic tumors are associated with a high incidence of perioperative AEs. Surgical duration predicts complications, reoperation, LOS, and ICU stay.
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Affiliation(s)
- Raphaële Charest-Morin
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Alana M Flexman
- 2Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Shreya Srinivas
- 3Department of Orthopaedics, Alder Hey Children's Hospital, NHS Foundation Trust, Liverpool, United Kingdom
| | - Charles G Fisher
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - John T Street
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Michael C Boyd
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Tamir Ailon
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Marcel F Dvorak
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Brian K Kwon
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Scott J Paquette
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
| | - Nicolas Dea
- 1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and
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Wu Y, Streijger F, Wang Y, Lin G, Christie S, Mac-Thiong JM, Parent S, Bailey CS, Paquette S, Boyd MC, Ailon T, Street J, Fisher CG, Dvorak MF, Kwon BK, Li L. Parallel Metabolomic Profiling of Cerebrospinal Fluid and Serum for Identifying Biomarkers of Injury Severity after Acute Human Spinal Cord Injury. Sci Rep 2016; 6:38718. [PMID: 27966539 PMCID: PMC5155264 DOI: 10.1038/srep38718] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/10/2016] [Indexed: 12/28/2022] Open
Abstract
Suffering an acute spinal cord injury (SCI) can result in catastrophic physical and emotional loss. Efforts to translate novel therapies in acute clinical trials are impeded by the SCI community's singular dependence upon functional outcome measures. Therefore, a compelling rationale exists to establish neurochemical biomarkers for the objective classification of injury severity. In this study, CSF and serum samples were obtained at 3 time points (~24, 48, and 72 hours post-injury) from 30 acute SCI patients (10 AIS A, 12 AIS B, and 8 AIS C). A differential chemical isotope labeling liquid chromatography mass spectrometry (CIL LC-MS) with a universal metabolome standard (UMS) was applied to the metabolomic profiling of these samples. This method provided enhanced detection of the amine- and phenol-containing submetabolome. Metabolic pathway analysis revealed dysregulations in arginine-proline metabolism following SCI. Six CSF metabolites were identified as potential biomarkers of baseline injury severity, and good classification performance (AUC > 0.869) was achieved by using combinations of these metabolites in pair-wise comparisons of AIS A, B and C patients. Using the UMS strategy, the current data set can be expanded to a larger cohort for biomarker validation, as well as discovering biomarkers for predicting neurologic outcome.
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Affiliation(s)
- Yiman Wu
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada
| | - Femke Streijger
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Yining Wang
- Department of Computing Science, University of Alberta, Edmonton, AB, T6T 2E8, Canada
| | - Guohui Lin
- Department of Computing Science, University of Alberta, Edmonton, AB, T6T 2E8, Canada
| | - Sean Christie
- Division of Neurosurgery, Dalhousie University, Halifax Infirmary, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Jean-Marc Mac-Thiong
- Hôpital du Sacré-Coeur de Montréal, 5400 Boul Gouin O, Montréal, QC, H4J 1C5, Canada
| | - Stefan Parent
- Chu Sainte-Justine, Dept. of Surgery, Université de Montréal, PO Box 6128, Station Centre-ville, Montreal, QC, H3C 3J7, Canada
| | - Christopher S Bailey
- Division of Orthopaedic Surgery, Schulich Medicine &Dentistry, Victoria Hospital 800 Commissioners Road East, Room E4 120, London, ON, N6C 5W9, Canada
| | - Scott Paquette
- Division of Neurosurgery, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Michael C Boyd
- Division of Neurosurgery, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Tamir Ailon
- Division of Neurosurgery, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - John Street
- Department of Orthopaedics, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Charles G Fisher
- Department of Orthopaedics, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Marcel F Dvorak
- Department of Orthopaedics, University of British Columbia, Vancouver Spine Surgery Institute, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Liang Li
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada
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Kwon BK, Streijger F, Fallah N, Noonan VK, Bélanger LM, Ritchie L, Paquette SJ, Ailon T, Boyd MC, Street J, Fisher CG, Dvorak MF. Cerebrospinal Fluid Biomarkers To Stratify Injury Severity and Predict Outcome in Human Traumatic Spinal Cord Injury. J Neurotrauma 2016; 34:567-580. [PMID: 27349274 DOI: 10.1089/neu.2016.4435] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Neurologic impairment after spinal cord injury (SCI) is currently measured and classified by functional examination. Biological markers that objectively classify injury severity and predict outcome would greatly facilitate efforts to evaluate acute SCI therapies. The purpose of this study was to determine how well inflammatory and structural proteins within the cerebrospinal fluid (CSF) of acute traumatic SCI patients predicted American Spinal Injury Association Impairment Scale (AIS) grade conversion and motor score improvement over 6 months. Fifty acute SCI patients (29 AIS A, 9 AIS B, 12 AIS C; 32 cervical, 18 thoracic) were enrolled and CSF obtained through lumbar intrathecal catheters to analyze interleukin (IL)-6, IL-8, monocyte chemotactic protein (MCP)-1, tau, S100β, and glial fibrillary acidic protein (GFAP) at 24 h post-injury. The levels of IL-6, tau, S100β, and GFAP were significantly different between patients with baseline AIS grades of A, B, or C. The levels of all proteins (IL-6, IL-8, MCP-1, tau, S100β, and GFAP) were significantly different between those who improved an AIS grade over 6 months and those who did not improve. Linear discriminant analysis modeling was 83% accurate in predicting AIS conversion. For AIS A patients, the concentrations of proteins such as IL-6 and S100β correlated with conversion to AIS B or C. Motor score improvement also was strongly correlated with the 24-h post-injury CSF levels of all six biomarkers. The analysis of CSF can provide valuable biological information about injury severity and recovery potential after acute SCI. Such biological markers may be valuable tools for stratifying individuals in acute clinical trials where variability in spontaneous recovery requires large recruitment cohorts for sufficient power.
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Affiliation(s)
- Brian K Kwon
- 1 Department of Orthopedics, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada .,2 International Collaboration on Repair Discoveries , Vancouver, British Columbia, Canada
| | - Femke Streijger
- 2 International Collaboration on Repair Discoveries , Vancouver, British Columbia, Canada
| | - Nader Fallah
- 3 Rick Hansen Institute , Vancouver, British Columbia, Canada .,4 Department of Medicine, University of British Columbia Vancouver , British Columbia, Canada
| | - Vanessa K Noonan
- 1 Department of Orthopedics, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada .,3 Rick Hansen Institute , Vancouver, British Columbia, Canada
| | - Lise M Bélanger
- 5 Vancouver Spine Program, Vancouver General Hospital , Vancouver, British Columbia, Canada
| | - Leanna Ritchie
- 5 Vancouver Spine Program, Vancouver General Hospital , Vancouver, British Columbia, Canada
| | - Scott J Paquette
- 6 Department of Surgery, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
| | - Tamir Ailon
- 6 Department of Surgery, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
| | - Michael C Boyd
- 6 Department of Surgery, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
| | - John Street
- 1 Department of Orthopedics, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
| | - Charles G Fisher
- 1 Department of Orthopedics, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
| | - Marcel F Dvorak
- 1 Department of Orthopedics, Vancouver Spine Surgery Institute , Vancouver, British Columbia, Canada
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Bailey CS, Urquhart JC, Dvorak MF, Nadeau M, Boyd MC, Thomas KC, Kwon BK, Gurr KR, Bailey SI, Fisher CG. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J 2014; 14:2557-64. [PMID: 24184649 DOI: 10.1016/j.spinee.2013.10.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 09/20/2013] [Accepted: 10/17/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Thoracolumbar burst fractures have good outcomes when treated with early ambulation and orthosis (TLSO). If equally good outcomes could be achieved with early ambulation and no brace, resource utilization would be decreased, especially in developing countries where prolonged bed rest is the default option because bracing is not available or affordable. PURPOSE To determine whether TLSO is equivalent to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures with respect to their functional outcome at 3 months. STUDY DESIGN A multicentre, randomized, nonblinded equivalence trial involving three Canadian tertiary spine centers. Enrollment began in 2002 and 2-year follow-up was completed in 2011. PATIENT SAMPLE Inclusion criteria included AO-A3 burst fractures between T11 and L3, skeletally mature and older than 60 years, 72 hours from their injury, kyphotic deformity lower than 35°, no neurologic deficit. One hundred ten patients were assessed for eligibility for the study; 14 patients were not recruited because they resided outside the country (3), refused participation (8), or were not consented before independent ambulation (3). OUTCOME MEASURES Roland Morris Disability Questionnaire score (RMDQ) assessed at 3 months postinjury. The equivalence margin was set at δ=5 points. METHODS The NO group was encouraged to ambulate immediately with bending restrictions for 8 weeks. The TLSO group ambulated when the brace was available and weaned from the brace after 8 to 10 weeks. The following competitive grants supported this work: VHHSC Interdisciplinary Research Grant, Zimmer/University of British Columbia Research Fund, and Hip Hip Hooray Research Grant. Aspen Medical provided the TLSOs used in this study. The authors have no financial or personal relationships that could inappropriately influence this work. RESULTS Forty-seven patients were enrolled into the TLSO group and 49 patients into the NO group. Forty-six participants per group were available for the primary outcome. The RMDQ score at 3 months postinjury was 6.8 ± 5.4 (standard deviation [SD]) for the TLSO group and 7.7 ± 6.0 (SD) in the NO group. The 95% confidence interval (-1.5 to 3.2) was within the predetermined margin of equivalence. Six patients required surgical stabilization, five of them before initial discharge. CONCLUSIONS Treating these fractures using early ambulation without a brace avoids the cost and patient deconditioning associated with a brace and complications and costs associated with long-term bed rest if a TLSO or body cast is not available.
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Affiliation(s)
- Christopher S Bailey
- Department of Surgery, Division of Orthopaedics, London Health Science Centre, University of Western Ontario, E4-120, 800 Commissioners Rd. E, London, Ontario N6A 4G5, Canada
| | - Jennifer C Urquhart
- Department of Surgery, Division of Orthopaedics, London Health Science Centre, University of Western Ontario, E4-120, 800 Commissioners Rd. E, London, Ontario N6A 4G5, Canada
| | - Marcel F Dvorak
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, 6th Floor Blusson Spinal Cord Centre, Vancouver, British Columbia V5Z 1M9, Canada
| | - Melissa Nadeau
- Department of Surgery, Division of Orthopaedics, London Health Science Centre, University of Western Ontario, E4-120, 800 Commissioners Rd. E, London, Ontario N6A 4G5, Canada
| | - Michael C Boyd
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, 6th Floor Blusson Spinal Cord Centre, Vancouver, British Columbia V5Z 1M9, Canada
| | - Ken C Thomas
- Department of Surgery (Orthopedics) and Neurosciences, University of Calgary, Foothills Medical Centre, 1403-29 St. N.W, Calgary, Alberta T2N-2T9, Canada
| | - Brian K Kwon
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, 6th Floor Blusson Spinal Cord Centre, Vancouver, British Columbia V5Z 1M9, Canada
| | - Kevin R Gurr
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, 6th Floor Blusson Spinal Cord Centre, Vancouver, British Columbia V5Z 1M9, Canada
| | - Stewart I Bailey
- Department of Surgery, Division of Orthopaedics, London Health Science Centre, University of Western Ontario, E4-120, 800 Commissioners Rd. E, London, Ontario N6A 4G5, Canada
| | - Charles G Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, 6th Floor Blusson Spinal Cord Centre, Vancouver, British Columbia V5Z 1M9, Canada.
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Gillis CC, Street JT, Boyd MC, Fisher CG. Pelvic reconstruction after subtotal sacrectomy for sacral chondrosarcoma using cadaveric and vascularized fibula autograft: Technical note. J Neurosurg Spine 2014; 21:623-7. [PMID: 25084027 DOI: 10.3171/2014.6.spine13657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A novel method of spinopelvic ring reconstruction after partial sacrectomy for a chondrosarcoma is described. Chondrosarcoma is one of the most common primary malignant bone tumors, and en bloc resection is the mainstay of treatment. Involvement of the pelvis as well as the sacrum and lumbar spine can result in a technically difficult challenge for en bloc resection and for achievement of appropriate load-bearing reconstruction. After en bloc resection in their patient, the authors achieved reconstruction with a rod and screw construct including vascularized fibula graft as the main strut from the lumbar spine to the pelvis. Additionally, a cadaveric allograft strut was used as an adjunct for the pelvic ring. This is similar to a modified Galveston technique with vascularized fibula in place of the Galveston rods. The vascularized fibula provided appropriate biomechanical support, allowing the patient to return to independent ambulation. There was no tumor recurrence; neurological status remained stable; and the allograft construct integrated well and even increased in size on CT scans and radiographs in the course of a follow-up longer than 7 years.
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Schouten R, Keynan O, Lee RS, Street JT, Boyd MC, Paquette SJ, Kwon BK, Dvorak MF, Fisher CG. Health-related quality-of-life outcomes after thoracic (T1-T10) fractures. Spine J 2014; 14:1635-42. [PMID: 24373680 DOI: 10.1016/j.spinee.2013.09.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 09/13/2013] [Accepted: 09/27/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The thoracic spine exhibits a unique response to trauma as the result of recognized anatomical and biomechanical differences. Despite this response, clinical studies often group thoracic fractures (T1-T10) with more caudal thoracolumbar injuries. Subsequently, there is a paucity of literature on the functional outcomes of this distinct group of injuries. PURPOSE To describe and identify predictors of health-related quality-of-life outcomes and re-employment status in patients with thoracic fractures who present to a spine injury tertiary referral center. STUDY DESIGN An ambispective cohort study with cross-sectional outcome assessment. PATIENT SAMPLE A prospectively collected fully relational spine database was searched to identify all adult (>16 years) patients treated with traumatic thoracic (T1-T10) fractures with and without neurologic deficits, treated between 1995 and 2008. OUTCOME MEASURES The Short-Form-36, Oswestry Disability Index, and Prolo Economic Scale outcome instruments were completed at a minimum follow-up of 12 months. Preoperative and minimum 1-year postinjury X-rays were evaluated. METHOD Univariate and multivariate regression analysis was used to identify predictors of outcomes from a range of demographic, injury, treatment, and radiographic variables. RESULTS One hundred twenty-six patients, age 36±15 years (mean±SD), with 135 fractures were assessed at a mean follow-up of 6 years (range 1-15.5 years). Traffic accidents (45%) and translational injuries (54%) were the most common mechanism and dominant fracture pattern, respectively. Neurologic deficits were frequent-53% had complete (American Spinal Injury Association impairment scale [AIS] A) spinal cord deficits on admission. Operative management was performed in 78%. Patients who sustain thoracic fractures, but escaped significant neurologic injury (AIS D or E on admission) had SF-36 scores that did not differ significantly from population norms at a mean follow-up of 6 years. Eighty-eight percent of this cohort was re-employed. Interestingly, Oswestry Disability Index scores remained inferior to healthy subjects. In contrast, SF-36 scores in those with more profound neurologic deficits at presentation (AIS A, B, or C) remained inferior to normative data. Fifty-seven percent were re-employed, 25% in their previous job type. Using multiple regression analysis, we found that comorbidity status (measured by the Charlson Comorbidity index) was the only independent predictor of SF-36 scores. Neurologic impairment (AIS) and adverse events were independent predictors of the SF-36 physical functioning subscale. Sagittal alignment and number of fused levels were not independent predictors. CONCLUSIONS At a mean follow-up of 6 years, patients who presented with thoracic fractures and AIS D or E neurologic status recovered a general health status not significantly inferior to population norms. Compared with other neurologic intact spinal injuries, patients with thoracic injuries have a favorable generic health-related quality-of-life prognosis. Inferior outcomes and re-employment prospects were noted in those with more significant neurologic deficits.
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Affiliation(s)
- Rowan Schouten
- Orthopaedic Department, Christchurch Hospital, Riccarton Ave., PO Box 4710, Christchurch 8140, New Zealand
| | - Ory Keynan
- Department of Orthopaedics, Tel Aviv Sourasky Medical Center, Weizmann 10, Tel Aviv, Israel
| | - Robert S Lee
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - John T Street
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - Michael C Boyd
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - Scott J Paquette
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - Brian K Kwon
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - Marcel F Dvorak
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada
| | - Charles G Fisher
- Department of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Blusson Spinal Cord Center, 818 West 10th Ave., Room 6196, Vancouver, British Columbia V5Z 1M9, Canada.
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Pouw MH, Kwon BK, Verbeek MM, Vos PE, van Kampen A, Fisher CG, Street J, Paquette SJ, Dvorak MF, Boyd MC, Hosman AJF, van de Meent H. Structural biomarkers in the cerebrospinal fluid within 24 h after a traumatic spinal cord injury: a descriptive analysis of 16 subjects. Spinal Cord 2014; 52:428-33. [DOI: 10.1038/sc.2014.26] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/11/2014] [Indexed: 11/09/2022]
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Kong CY, Hosseini AM, Belanger LM, Ronco JJ, Paquette SJ, Boyd MC, Dea N, Street J, Fisher CG, Dvorak MF, Kwon BK. A prospective evaluation of hemodynamic management in acute spinal cord injury patients. Spinal Cord 2014; 51:466-71. [PMID: 23743499 DOI: 10.1038/sc.2013.32] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective observational study of acute spinal cord-injured (SCI) patients. OBJECTIVES To determine how effectively mean arterial blood pressure (MAP) and spinal cord perfusion pressure (SCPP) are maintained at target levels in acute SCI patients. SETTING Single-institution study at a Canadian level-one trauma center. METHODS Twenty-one individuals with cervical or thoracic SCI were enrolled within 48 h of injury. A lumbar intrathecal drain was inserted for monitoring intrathecal cerebrospinal fluid pressure (ITP). The MAP was monitored concurrently with ITP, and the SCPP was calculated. Data was recorded hourly from the time of first assessment until at least the end of the 5th day post injury. RESULTS All subjects had at least one recorded episode with a MAP below 80 mm Hg, and 81% had at least one episode with a MAP below 70 mm Hg. On average, subjects with cervical injuries had 18.4% of their pressure recordings below 80 mm Hg. Subjects with thoracic cord injuries had on average 35.9% of their MAP recordings <80 mm Hg. CONCLUSION It is common practice to establish MAP targets for optimizing cord perfusion in acute SCI. This study suggests that even in an acute SCI referral center, when prospectively scrutinized, the actual MAP may frequently fall below the intended targets. Such results raise awareness of the vigilance that must be kept in the hemodynamic management of these patients, and the potential discrepancy between routinely setting target MAP according to 'practice guidelines' and actually achieving them.
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Affiliation(s)
- C Y Kong
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Dipaola CP, Saravanja DD, Boriani L, Zhang H, Boyd MC, Kwon BK, Paquette SJ, Dvorak MFS, Fisher CG, Street JT. Postoperative infection treatment score for the spine (PITSS): construction and validation of a predictive model to define need for single versus multiple irrigation and debridement for spinal surgical site infection. Spine J 2012; 12:218-30. [PMID: 22386957 DOI: 10.1016/j.spinee.2012.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 09/22/2011] [Accepted: 02/07/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps. PURPOSE The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment. STUDY DESIGN A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database. METHODS More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated. RESULTS Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46. CONCLUSIONS Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.
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Affiliation(s)
- Christian P Dipaola
- Department of Orthopaedics, University of Massachusetts Medical Center, Worcester, MA 01605, USA.
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Abstract
Penetrating limb injuries are common during conflict, and in many there will be an associated fracture. Treatment of ballistic femoral fractures would usually be with by intramedullary nail; however, within the resource-constrained environment during conflict this is rarely possible. This report illustrates what can be achieved at a Role 2 facility to provide skeletal traction with the equipment and skills available. We discuss the history of skeletal traction and its use in ballistic femoral fractures, and believe that skeletal traction is still a valuable technique that we shouldn't ignore. Military surgeons should be able to use skeletal traction to manage ballistic femoral fractures in the spartan environment of a deployed forward hospital.
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Affiliation(s)
- M C Boyd
- The Household Cavalry Regiment, Combermere Barracks, Windsor.
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Kwon BK, Stammers AM, Belanger LM, Bernardo A, Chan D, Bishop CM, Slobogean GP, Zhang H, Umedaly H, Giffin M, Street J, Boyd MC, Paquette SJ, Fisher CG, Dvorak MF. Cerebrospinal Fluid Inflammatory Cytokines and Biomarkers of Injury Severity in Acute Human Spinal Cord Injury. J Neurotrauma 2010; 27:669-82. [DOI: 10.1089/neu.2009.1080] [Citation(s) in RCA: 213] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Brian K. Kwon
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthea M.T. Stammers
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Lise M. Belanger
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Arlene Bernardo
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Donna Chan
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Carole M. Bishop
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Gerard P. Slobogean
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hongbin Zhang
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Hamed Umedaly
- Department of Anaesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mitch Giffin
- Department of Anaesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Street
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael C. Boyd
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Surgery, Division of Neurosurgery, University of British Columbia Vancouver, British Columbia, Canada
| | - Scott J. Paquette
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Surgery, Division of Neurosurgery, University of British Columbia Vancouver, British Columbia, Canada
| | - Charles G. Fisher
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel F. Dvorak
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Bailey CS, Dvorak MF, Thomas KC, Boyd MC, Paquett S, Kwon BK, France J, Gurr KR, Bailey SI, Fisher CG. Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: interim analysis of a multicenter randomized clinical equivalence trial. J Neurosurg Spine 2009; 11:295-303. [PMID: 19769510 DOI: 10.3171/2009.3.spine08312] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors compared the outcome of patients with thoracolumbar burst fractures treated with and without a thoracolumbosacral orthosis (TLSO).
Methods
As of June 2002, all consecutive patients satisfying the following inclusion criteria were considered eligible for this study: 1) the presence of an AO Classification Type A3 burst fractures between T-11 and L-3, 2) skeletal maturity and age < 60 years, 3) admission within 72 hours of injury, 4) initial kyphotic deformity < 35°, and 5) no neurological deficit. The study was designed as a multicenter prospective randomized clinical equivalence trial. The primary outcome measure was the score based on the Roland-Morris Disability Questionnaire assessed at 3 months postinjury. Secondary outcomes are assessed until 2 years of follow-up have been reached, and these domains included pain, functional outcome and generic health-related quality of life, sagittal alignment, length of hospital stay, and complications. Patients in whom no orthotic was used were encouraged to ambulate immediately following randomization, maintaining “neutral spinal alignment” for 8 weeks. The patients in the TLSO group began being weaned from the brace at 8 weeks over a 2-week period.
Results
Sixty-nine patients were followed to the primary outcome time point, and 47 were followed for up to 1 year. No significant difference was found between treatment groups for any outcome measure at any stage in the follow-up period. There were 4 failures requiring surgical intervention, 3 in the TLSO group and 1 in the non-TLSO group.
Conclusions
This interim analysis found equivalence between treatment with a TLSO and no orthosis for thoracolumbar AO Type A3 burst fractures. The influence of a brace on early pain control and function and on long-term 1- and 2-year outcomes remains to be determined. However, the authors contend that a thoracolumbar burst fracture, in exclusion of an associated posterior ligamentous complex injury, is inherently a very stable injury and may not require a brace.
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Affiliation(s)
| | - Marcel F. Dvorak
- 2Vancouver Hospital and Health Sciences, University of British Columbia, Vancouver, British Columbia
| | - Kenneth C. Thomas
- 3Department of Surgery (Orthopedics) and Neurosciences, University of Calgary, Alberta, Canada; and
| | - Michael C. Boyd
- 2Vancouver Hospital and Health Sciences, University of British Columbia, Vancouver, British Columbia
| | - Scott Paquett
- 2Vancouver Hospital and Health Sciences, University of British Columbia, Vancouver, British Columbia
| | - Brian K. Kwon
- 2Vancouver Hospital and Health Sciences, University of British Columbia, Vancouver, British Columbia
| | - John France
- 4Orthopedics Department, University of West Virginia, Morgantown, West Virginia
| | - Kevin R. Gurr
- 1London Health Science Centre, University of Western Ontario, London, Ontario
| | - Stewart I. Bailey
- 1London Health Science Centre, University of Western Ontario, London, Ontario
| | - Charles G. Fisher
- 2Vancouver Hospital and Health Sciences, University of British Columbia, Vancouver, British Columbia
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Kwon BK, Curt A, Belanger LM, Bernardo A, Chan D, Markez JA, Gorelik S, Slobogean GP, Umedaly H, Giffin M, Nikolakis MA, Street J, Boyd MC, Paquette S, Fisher CG, Dvorak MF. Intrathecal pressure monitoring and cerebrospinal fluid drainage in acute spinal cord injury: a prospective randomized trial. J Neurosurg Spine 2009; 10:181-93. [PMID: 19320576 DOI: 10.3171/2008.10.spine08217] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT Ischemia is an important factor in the pathophysiology of secondary damage after traumatic spinal cord injury (SCI) and, in the setting of thoracoabdominal aortic aneurysm repair, can be the primary cause of paralysis. Lowering the intrathecal pressure (ITP) by draining CSF is routinely done in thoracoabdominal aortic aneurysm surgery but has not been evaluated in the setting of acute traumatic SCI. Additionally, while much attention is directed toward maintaining an adequate mean arterial blood pressure (MABP) in the acute postinjury phase, little is known about what is happening to the ITP during this period when spinal cord perfusion pressure (MABP - ITP) is important. The objectives of this study were to: 1) evaluate the safety and feasibility of draining CSF to lower ITP after acute traumatic SCI; 2) evaluate changes in ITP before and after surgical decompression; and 3) measure neurological recovery in relation to the drainage of CSF. METHODS Twenty-two patients seen within 48 hours of injury were prospectively randomized to a drainage or no-drainage treatment group. In all cases a lumbar intrathecal catheter was inserted for 72 hours. Acute complications of headache/nausea/vomiting, meningitis, or neurological deterioration were carefully monitored. Acute Spinal Cord Injury motor scores were documented at baseline and at 6 months postinjury. RESULTS On insertion of the catheter, mean ITP was 13.8 +/- 1.3 mm Hg (+/- SD), and it increased to a mean peak of 21.7 +/- 1.5 mm Hg intraoperatively. The difference between the starting ITP on catheter insertion and the observed peak intrathecal pressure after decompression was, on average, an increase of 7.9 +/- 1.6 mm Hg (p < 0.0001, paired t-test). During the postoperative period, the peak recorded ITP in the patients randomized to the no-drainage group was 30.6 +/- 2.3 mm Hg, which was significantly higher than the peak intraoperative ITP (p = 0.0098). During the same period, the peak recorded ITP in patients randomized to receive drainage was 28.1 +/- 2.8 mm Hg, which was not statistically higher than the peak intraoperative ITP (p = 0.15). CONCLUSIONS The insertion of lumbar intrathecal catheters and the drainage of CSF were not associated with significant adverse events, although the cohort was small and only a limited amount of CSF was drained. Intraoperative decompression of the spinal cord results in an increase in the ITP measured caudal to the injury site. Increases in intrathecal pressure are additionally observed in the postoperative period. These increases in intrathecal pressure result in reduced spinal cord perfusion that will otherwise go undetected when measuring only the MABP. Characteristic changes in the observed intrathecal pressure waveform occur after surgical decompression, reflecting the restoration of CSF flow across the SCI site. As such, the waveform pattern may be used intraoperatively to determine if adequate decompression of the thecal sac has been accomplished.
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Affiliation(s)
- Brian K Kwon
- Departments of Orthopaedics, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Canada.
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Kwon BK, Fisher CG, Boyd MC, Cobb J, Jebson H, Noonan V, Wing P, Dvorak MF. A prospective randomized controlled trial of anterior compared with posterior stabilization for unilateral facet injuries of the cervical spine. J Neurosurg Spine 2007; 7:1-12. [PMID: 17633481 DOI: 10.3171/spi-07/07/001] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECT Unilateral facet injuries can be treated with either anterior or posterior fixation techniques with reportedly good outcomes. The two approaches have not been directly compared, however, and consensus is lacking as to which is the optimal method. The primary objective of this study was to determine whether acute postoperative morbidity differed between anteriorly and posteriorly treated patients with unilateral facet injuries. METHODS Forty-two patients were prospectively randomized to undergo either anterior cervical discectomy and fusion or posterior fixation. The primary outcome measure was the postoperative time required to achieve a predefined set of discharge criteria. Secondary outcome measures included postoperative pain, wound infections, radiographically demonstrated fusion and alignment, and patient-reported outcome measures. RESULTS The median time to achieve the discharge criteria was 2.75 and 3.5 days for anterior and posterior groups, respectively, a difference that did not reach statistical significance (p = 0.096). Compared with those treated using posterior fixation, anteriorly treated patients exhibited somewhat less postoperative pain, a lower rate of wound infection, a higher rate of radiographically demonstrated union, and better radiographically proven alignment. Nonetheless, the anterior approach was accompanied by a risk of swallowing difficulty in the early postoperative period. Patient-reported outcome measures did not reveal a difference between anterior and posterior fixation procedures. CONCLUSIONS This prospective randomized controlled trial provided level 1 evidence that both the anterior and posterior fixation approaches appear to be valid treatment options. Although statistical significance was not reached in the primary outcome measure, some secondary outcome measures favored anterior fixation and others favored posterior treatment for unilateral facet injuries.
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Affiliation(s)
- Brian K Kwon
- Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedics University of British Columbia; V anada.
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15
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Smith A, Boyd MC, Bulman M, Shenton A, Lalloo F, Evans DGR, Moran A, Iddenden R, Smith L, Woodward ER, Maher ER. Response to correspondence on "Phenocopies in BRCA1 and BRCA2 families: evidence for modifier genes and implications for screening". J Med Genet 2007. [DOI: 10.1136/jmg.2007.051722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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16
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Smith A, Moran A, Boyd MC, Bulman M, Shenton A, Smith L, Iddenden R, Woodward ER, Lalloo F, Maher ER, Evans DGR. Phenocopies in BRCA1 and BRCA2 families: evidence for modifier genes and implications for screening. J Med Genet 2007; 44:10-15. [PMID: 17079251 PMCID: PMC2597903 DOI: 10.1136/jmg.2006.043091] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2006] [Revised: 07/11/2006] [Accepted: 07/19/2006] [Indexed: 01/07/2023]
Abstract
BACKGROUND The identification of BRCA1 and BRCA2 mutations in familial breast cancer kindreds allows genetic testing of at-risk relatives. Those who test negative are usually reassured and additional breast cancer surveillance is discontinued. However, we postulated that in high-risk families, such as those seen in clinical genetics centres, the risk of breast cancer might be influenced not only by the BRCA1/BRCA2 mutation but also by modifier genes. One manifestation of this would be the presence of phenocopies in BRCA1/BRCA2 kindreds. METHODS 277 families with pathogenic BRCA1/BRCA2 mutations were reviewed and 28 breast cancer phenocopies identified. The relative risk of breast cancer in those testing negative was assessed using incidence rates from our cancer registry based on local population. RESULTS Phenocopies constituted up to 24% of tests on women with breast cancer after the identification of the mutation in the proband. The standardised incidence ratio for women who tested negative for the BRCA1/BRCA2 family mutation was 5.3 for all relatives, 5.0 for all first-degree relatives (FDRs) and 3.2 (95% confidence interval 2.0 to 4.9) for FDRs in whose family all other cases of breast and ovarian cancer could be explained by the identified mutation. 13 of 107 (12.1%) FDRs with breast cancer and no unexplained family history tested negative. CONCLUSION In high-risk families, women who test negative for the familial BRCA1/BRCA2 mutation have an increased risk of breast cancer consistent with genetic modifiers. In light of this, such women should still be considered for continued surveillance.
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Affiliation(s)
- A Smith
- Academic Unit of Medical Genetics and Regional Genetics Service, St Mary's Hospital, Manchester, UK
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Abstract
STUDY DESIGN Prospective clinical study. OBJECTIVE To assess Health-Related Quality of Life outcomes in patients undergoing surgery for spinal metastases. SUMMARY OF BACKGROUND DATA Increasing life expectancy of patients with spinal metastases has resulted in greater interest in overall quality of life, including pain and neurologic impairment. To assess the overall risks and benefits of surgical intervention, the overall impact of each on the overall health status must be assessed. METHODS All patients who presented to a single institution with bony spinal metastases requiring surgical intervention were eligible. EXCLUSION CRITERIA previous surgery for spinal metastases, primary tumors of the spine, and inability to fill out the questionnaires. Patients completed an EORTC QLQ-C30, the HUI-3, the EQ-5D, visual analog pain, and an ECOG functional assessment. at five points: before surgery and at 6 weeks, 3 months, 6 months, and 1 year post surgery. RESULTS Of 96 patients who presented to the hospital, 85 were enrolled in the study. Average age was 58.6 years (range, 20.3-80.7 years) with 47 male patients; 50% survival as 39.1 weeks. Maximal and average VAS pain levels showed a statistically significant (P < 0.00001) improvement from preoperative to all postoperative time points. Only the QLQ-C30 global health status showed a statistically significant improvement from preoperative to the 6-week (P = 0.017), 3-month (P = 0.039), and 6-month (P = 0.013) time points. There was a statistically significant correlation between baseline global health status and survival time (P = 0.041). Overall distribution of HUI-3 utility calculated Quality of Life Adjusted Years (QALY) during the 1-year postoperative period showed a bimodal distribution with peaks at 0.1 and 0.7 years. CONCLUSIONS Surgery for patients with spinal metastases offers decreased pain and improved quality of life with low rates of surgical complications.
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Affiliation(s)
- Alexis Falicov
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Kwon BK, Elgafy H, Keynan O, Fisher CG, Boyd MC, Paquette SJ, Dvorak MF. Progressive junctional kyphosis at the caudal end of lumbar instrumented fusion: etiology, predictors, and treatment. Spine (Phila Pa 1976) 2006; 31:1943-51. [PMID: 16924211 DOI: 10.1097/01.brs.0000229258.83071.db] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Clinical case series. OBJECTIVE To describe a series of patients with progressive sagittal decompensation caused by failure at the caudal end of an instrumented lumbar fusion. SUMMARY OF BACKGROUND DATA Lumbar kyphosis in association with global sagittal decompensation can be a disabling problem, particularly as a late complication of distraction instrumentation. Although kyphosis at the rostral end of instrumented fusions secondary to adjacent segment degeneration has been well described, substantially less has been documented about failure and kyphosis at the caudal end. METHODS Patients who have a progressive lumbar kyphosis and sagittal decompensation requiring operative revision were retrospectively reviewed, and radiographic measurements of lumbar lordosis and sagittal balance were performed to study this problem. RESULTS There were 13 patients identified. The most common mode of caudal junctional decompensation was related to failure of the most distal fixation. Sagittal decompensation occurred even in the presence of satisfactory lumbar lordosis. Revision surgery and improved sagittal balance were achieved typically using the technique of pedicle subtraction osteotomy and extension of the instrumentation to the sacrum. Osteoporosis, hip osteoarthritis, and substance abuse were commonly observed associations. CONCLUSIONS Fixation failure at the caudal end of lumbar-instrumented fusion should be considered in patients with progressive sagittal decompensation. The high potential for failure of L5 pedicle screws after the index surgery warrants serious consideration of extending such fusions into the sacrum/ilium.
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Affiliation(s)
- Brian K Kwon
- Division of Spine, Department of Orthopaedics, University of British Columbia Vancouver, Canada
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Abstract
✓ The purpose of this case report is to demonstrate that an en bloc resection with negative surgical margins can be successfully achieved in a case of a seemingly unresectable C-2 chordoma if appropriate preoperative staging and planning are performed. The management of chordomas is controversial and challenging because of their location and often large size at presentation. Because chordomas are malignant and will aggressively recur locally if intralesional resection is conducted, wide or true en bloc resection is generally recommended. The literature indicates, however, that surgeons are reluctant to perform wide or even marginal resections because of the lesion’s complex surrounding anatomy and the risk of significant neurological compromise when a tumor abuts the dura mater or neural tissues. In this report the authors outline the successful en bloc resection of a large C1–3 chordoma and discuss the importance of preoperative staging and planning.
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Affiliation(s)
- Christopher S Bailey
- Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedics, University of British Columbia, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada
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Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES To prospectively validate the application of appendicular surgical oncology principles to the treatment of primary bone tumors of the spine at a quaternary care spine center using local recurrence, survival, and health-related quality of life as outcome measures. SUMMARY OF BACKGROUND DATA There is clear evidence that violating the margins of a sarcoma or other malignancy during surgical resection will risk local recurrence and diminish overall survival. Previous publications have retrospectively demonstrated this oncologically sound approach to spine tumor management to be internally valid. The external validity or limited generalizability has not been assessed. METHODS Included were all patients who underwent en bloc surgical resection of a primary tumor of the spine between January 1994 and November 2003, at the authors' institution. Patients were uniformly staged before surgery and baseline demographic and surgical variables were recorded, as well as a cross-sectional evaluation of generic health-related quality of life. RESULTS Twenty-six patients (12 males and 14 females) were eligible for the study. Average age was 42 (range 16 to 70). There were 19 malignant tumors and 7 benign. There are 20 surviving patients with an average follow-up of 41.5 months (range 6 to 111 months), 15 of whom had malignant tumors. None of these patients have evidence of local recurrence, and one has evidence of systemic disease. The health-related quality of life, using the SF-36, shows acceptable morbidity of these procedures (physical component summary = 37.73 +/- 11.52, MCS = 51.69 +/- 9.54). CONCLUSIONS Principles of wide surgical resection, commonly applied in appendicular oncology, can and should be used for the treatment of primary bone tumors of the spine with anticipated acceptable morbidity and satisfactory survival.
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Affiliation(s)
- Charles G Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia and the Combined Neurosurgical and Orthopaedic Spine Program at the Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada.
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Keynan O, Fisher CG, Boyd MC, O'Connell JX, Dvorak MF. Ligation and partial excision of the cauda equina as part of a wide resection of vertebral osteosarcoma: a case report and description of surgical technique. Spine (Phila Pa 1976) 2005; 30:E97-102. [PMID: 15706330 DOI: 10.1097/01.brs.0000153396.39009.a3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report. OBJECTIVES To describe the unique challenges and novel surgical approach to treatment of vertebral osteosarcoma involving the dura as a margin. SUMMARY OF BACKGROUND DATA Osteosarcoma of the vertebral column is a rare, malignant osseous tumor, carrying a poor prognosis. Currently, best available evidence supports that optimal surgical treatment entails wide excision of the tumor. Intentionally compromising neurologic function in order to ensure resection of the tumor with wide surgical margins can pose a difficult dilemma for the surgeon and patient. We describe here the first reported case, to our knowledge, of wide surgical resection of a vertebral osteosarcoma, including ligation and resection of part of the cauda equina and conus medullaris. METHODS The clinical and radiographic presentations of a patient with osteosarcoma of L2 are presented. The challenges of surgical treatment of a primary malignant tumor of the spine, involving the dura as a margin, are discussed. The ultimate surgical technique employed to achieve wide surgical margins is described in detail. RESULTS Four-year follow-up shows the patient is doing well, ambulating in a wheelchair, with no clinical or radiologic evidence of active disease or back or neuropathic pain and solid bony fusion. CONCLUSION Currently, there is sufficient evidence to support the premise that the best chance for cure in sarcomas of the spine can be afforded through en bloc resection with negative margins. Neurologic forfeit in resection of spinal tumors, however, is usually at the root level, and this is the only case where such dramatic neurologic sacrifice was carried out. Although it is still early, the surgical and medical goals have been met, but most importantly, the patient's foremost goal of survival has been accomplished.
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Affiliation(s)
- Ory Keynan
- Division of Spine, Department of Orthopaedics, University of British Columbia and the Combined Neurosurgical and Orthopaedic Spine Program at the Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada
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Dvorak MF, Noonan VK, Bélanger L, Bruun B, Wing PC, Boyd MC, Fisher C. Early versus late enteral feeding in patients with acute cervical spinal cord injury: a pilot study. Spine (Phila Pa 1976) 2004; 29:E175-80. [PMID: 15105682 DOI: 10.1097/00007632-200405010-00020] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized clinical pilot study to compare early versus late enteral feeding in patients with acute cervical spinal cord injury. OBJECTIVES To compare the incidence of infections in patients with acute cervical spinal cord injury who received early versus late enteral feeding. Secondary objectives included assessing nutritional status, feeding tolerance, the number of ventilator hours, and acute-care hospital length of stay. SUMMARY OF BACKGROUND DATA Early nutritional support has been found to be beneficial in critically ill patients. However, the same benefits may not be realized in patients with acute cervical spinal cord injury because of their unique nutritional challenges. METHODS Eligible patients were randomized to early feeding (initiated before 72 hours after injury) and late (initiated more than 120 hours after injury). Patients were stratified on the basis of their neurologic level. Patients were assessed daily for the first 15 days. After that time, infections (according to Center for Disease Control criteria), ventilator hours, and length of acute-care hospital stay were tracked. RESULTS Twenty-three patients met the eligibility criteria, and 17 patients were included in the analysis. There were 7 patients in the early group and 10 in the late group. The early group had a mean of 2.4 +/- 1.5 infections compared with the late group, which had a mean of 1.7 +/- 1.1 infections. Secondary outcomes were not substantially different between the two groups. CONCLUSIONS This pilot study failed to detect any differences in the incidence of infection, nutritional status, feeding complications, number of ventilator hours, or length of stay between patients receiving early versus late initiation of enteral feeding. These data will assist in the determination of an adequate sample size for future studies.
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Affiliation(s)
- Marcel F Dvorak
- Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
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Cornford ME, Holden JK, Boyd MC, Berry K, Vinters HV. Neuropathology of the acquired immune deficiency syndrome (AIDS): report of 39 autopsies from Vancouver, British Columbia. Neurol Sci 1992; 19:442-52. [PMID: 1330261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neuropathological findings from 39 acquired immune deficiency syndrome (AIDS) autopsies of primarily neurologically symptomatic patients and 7 brain biopsies from AIDS patients performed at St. Paul's Hospital, Vancouver, British Columbia are reported. Autopsy findings included human immunodeficiency virus-1 (HIV)-type multinucleated giant cell (MNGC)-associated encephalitis seen in 17 patients, toxoplasmosis in 7 patients, and cytomegalovirus encephalitis and/or microglial nodule-associated nuclear inclusions in brain parenchyma in 9 patients. Central nervous system lymphoma was identified in 11 autopsy patients and in 4 of 7 brain biopsies. Infectious processes including HIV encephalitis were seen in 10 of 11 autopsied patients with lymphoproliferative lesions in the brain parenchyma, while 40% of patients without lymphoma had HIV-type MNGC or opportunistic infections. CNS lymphoma was not significantly increased in incidence in patients with a clinical history of zidovudine treatment, but increased duration of survival after the diagnosis of AIDS was associated with increased incidence of lymphoma in both untreated and zidovudine-treated patients. Patients displaying HIV MNGC within microglial nodules had a shorter mean duration of survival after diagnosis of AIDS than those patients with HIV encephalitis with dispersed MNGC, white matter vacuolation, and gliosis.
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Affiliation(s)
- M E Cornford
- Department of Pathology, UCLA Center for Health Sciences 90024-1732
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Abstract
Choroid plexus tumors are uncommon neoplasms of the central nervous system. A series of 11 cases from the Vancouver General and British Columbia Children's Hospitals, treated during the last 12 years, are reviewed. Some of the management problems commonly encountered with these tumors are discussed. Many of these tumors are associated with severe hydrocephalus at the time of diagnosis, and the perioperative management of this hydrocephalus remains a matter of some debate. The timing of and the necessity for shunting are major considerations. Large subdural fluid collections are often discovered in the postoperative period, and these occasionally cause symptoms of increased intracranial pressure. Reasons for this problem are suggested and possible steps for its prevention are proposed. The similarity between papillary ependymomas and choroid plexus papillomas has sometimes caused difficulty in pathological diagnosis. Choroid plexus carcinomas, of which there were two in this series, also present a diagnostic challenge. Differential diagnosis affects the further treatment and prognosis for the patient.
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Abstract
Localized periaqueductal tumors usually present as hydrocephalus, which is then thought to be late-onset congenital aqueductal narrowing. In the past, radiological investigations, including positive contrast ventriculography, pneumoencephalography and even contrast CT scanning, have frequently failed to show tumors in this region in the early stages. However, recent experience using MRI on patients with unexplained late-onset aqueductal stenosis has in some instances shown the presence of a localized periaqueductal tumor as the cause of obstruction of the aqueduct. Four patients are described with hydrocephalus secondary to presumed late-onset congenital aqueductal stenosis, all of whom were shown to have a periaqueductal tumor. One patient had been investigated with a pneumoencephalogram and positive contrast ventriculogram and CT with an early-generation scanner, but the tumor was diagnosed only at the time of autopsy. In one patient, the tumor was diagnosed by CT and also confirmed with MRI; a histologic diagnosis has been obtained. In two other patients, CT with and without contrast enhancement was negative and in one of these, a positive contrast ventriculogram was also negative, but the tumor was easily identified on MRI scans. In both of these patients, a histologic diagnosis was obtained by stereotactic biopsy. Periaqueductal tumors must be considered in the differential diagnosis of patients who present with late onset aqueductal occlusion and in such patients, MRI would appear to be the investigation of choice.
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Affiliation(s)
- P Steinbok
- Department of Neurosurgery, B.C. Children's Hospital, Vancouver, Canada
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Abstract
Familial arteriovenous malformations (AVM's) are uncommon entities, with only seven reported cases in the English literature. Some have been associated with hereditary telangiectasia. A family in which AVM's were found in four male members of two generations is reported. In addition, one patient had a large cyst associated with his AVM without previous evidence of acute hemorrhage, which is an uncommon presentation. The family is discussed and a brief review of the literature is presented.
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Abstract
A unique method for closed reduction of lumbosacral fracture dislocations that uses a circle-electric bed is described. Fine radiological description of the injury with computed tomography scanning allows the application of appropriate forces to facilitate the reduction, while having the patient awake during the procedure greatly reduces the chance of introducing further neurological deficit.
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Abstract
The management of pineal region tumors has changed considerably since the introduction of microsurgery and CT scanning. Analysis of our own series of 36 patients, comparing those treated in the pre-CT scan and microsurgery era with those treated afterwards, shows the important role these two techniques play. Current controversies in treatment and our own approach to management of pineal region tumors are discussed.
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Abstract
High resolution ultrasound has been used intraoperatively on forty-five patients with various intracranial lesions. The technique is quickly and easily carried out under sterile conditions in the operating room. Successful localization of both primary and metastatic tumors of various sizes, depths and consistencies have been made prior to extirpation or biopsy. Several of the biopsies were done through small burr holes. Arteriovenous malformations, abscesses, bone fragments from trauma, gliotic epileptic foci and ventricles for shunt placement have been readily found. No significant complications have been encountered. A new technique for localizing superficial lesions is described. An overall reduction in operating time and unnecessary trauma to the patient has resulted from more accurate intraoperative localization of intracranial lesions with real time ultrasound.
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Abstract
A prospective study was undertaken to elucidate the effect, if any, of total parenteral nutrition on plasma Antithrombin III levels. A total of 309 patients were included in the study. The patients suffered from cancer, or chronic illness, or major trauma which necessitated total parenteral nutrition. Each patient acted as his own control. Pre and postinfusion Antithrombin III levels were measured at regular intervals. Statistically, the results of the study have shown that total parenteral nutrition does not significantly alter Antithrombin III levels.
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Innis SM, Boyd MC. Cholesterol and bile acid synthesis during total parenteral nutrition with and without lipid emulsion in the rat. Am J Clin Nutr 1983; 38:95-100. [PMID: 6407300 DOI: 10.1093/ajcn/38.1.95] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The origin of excess plasma free cholesterol known to accumulate in plasma of patients or animals given total parenteral nutrition (TPN) with lipid emulsion was investigated. Rats were infused for 8 days with a specially formulated TPN solution plus either lipid emulsion (lipid-TPN) or an equicaloric volume of 25% dextrose (dextrose-TPN). Laboratory diet-fed controls were sham operated. Lipid-TPN suppressed hepatic HMG CoA reductase (HMG CoAR) activity but elevated cholesterol 7 alpha-hydroxylase (7 alpha-OH) activity. HMG CoAR activity, however, was increased in adipose tissue and skeletal muscle by lipid-TPN when compared to dextrose-TPN. Plasma lecithin/cholesterol acyl transfer activity was similar among all groups. It is suggested that in lipid-TPN excess plasma free cholesterol does not arise from decreased hepatic clearance or plasma esterification but may originate from extrahepatic tissue, possibly through leaching of membrane cholesterol by mesophase phospholipid present in the lipid emulsion. The changes in hepatic HMG CoAR and 7 alpha-OH activity imply that during lipid-TPN plasma free cholesterol is cleared by the liver and catabolized to bile acid.
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