Combination radiofrequency ablation and vertebral cement augmentation for spinal metastatic tumors: A systematic review and meta-analysis of safety and treatment outcomes.

Background: The treatment of spine metastases continues to pose a significant clinical challenge, requiring the integration of multiple therapeutic modalities to address the multifactorial aspects of this disease process. Radiofrequency ablation (RFA) and vertebral cement augmentation (VCA) are 2 less invasive modalities compared to open surgery that have emerged as promising strategies, offering the potential for both pain relief and preservation of vertebral stability. The utility of these approaches, however, remains uncertain and subject to ongoing investigation.This systematic review and meta-analysis evaluates the available evidence and synthesize the results of studies that have investigated the combination of RFA and VCA for the treatment of spinal metastases, with the goal of providing a comprehensive and up-to-date assessment of the efficacy and safety of this therapeutic approach. Methods: A literature search was conducted using the electronic databases PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus from their inception to May 4th, 2022 in accordance with PRISMA guidelines. Studies were included if they met the following criteria: 1) spine metastases treated with RFA in combination with VCA, 2) available data on at least one outcome (i.e., pain palliation, complications, local tumor control), 3) prospective or retrospective studies with at least 10 patients, and 4) English language. Meta-analyses were conducted in R (R Foundation for Statistical Computing; Vienna, Austria), using the meta package. Results: In the 25 included studies, a total of 947 patients (females=53.9%) underwent RFA + VCA for spinal metastatic tumors. Out of 1,163 metastatic lesions, the majority were located in the lumbar region (585/1,163 [50.3%]) followed by thoracic (519/1,163 [44.6%]), sacrum (39/1,163 [3.4%]), and cervical (2/1,163 [0.2%]). 48/72 [66.7%] metastatic lesions expanded into the posterior elements. Preoperative pathologic vertebral fractures were identified in 115/176 [65.3%] patients. Between pre-procedure pain scores and postprocedure pain scores, average follow-up (FU) was 4.41±2.87 months. Pain scores improved significantly at a short-term FU (1-6 months), with a pooled mean difference (MD) from baseline of 4.82 (95% CI, 4.48-5.16). The overall local tumor progression (LTP) rate at short-term FU (1-6 months) was 5% (95% CI, 1%-8%), at mid-term FU (6-12 months) was 22% (95% CI, 0%-48%), and at long-term FU (>12 months) was 5% (95% CI, 0%-11%). The pooled incidence of total complications was 1% (95% CI, 0%-1%), the most frequent of which were transient radicular pain and asymptomatic cement extravasation. Conclusions: The findings of this meta-analysis reveal that the implementation of RFA in conjunction with VCA for the treatment of spinal metastatic tumors resulted in a significant short-term reduction of pain, with minimal total complications. The LTP rate was additionally low. The clinical efficacy and safety of this technique are established, although further exploration of the long-term outcomes of RFA+VCA is warranted.

Dosing Strategy for Osteobiologics Used in ACDF Surgery: Influence on Fusion Rates and Associated Complications. A Systematic Literature Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To assess the available evidence related to dose-dependent effectiveness (i.e., bone fusion) and morbidity of osteobiologics used in anterior cervical discectomy and fusion (ACDF). METHODS: Studies with more than 9 adult patients with degenerated/herniated cervical discs operated for one-to four-levels ACDF reporting used osteobiologics doses, fusion rates at six months or later, and related comorbidities were included. PubMed, EMBASE, ClinicalTrials, and Cochrane were searched through September 2021. Data extracted in spread sheet and risk of bias assessed using MINORS and Rob-2. RESULTS: Sixteen studies were selected and sub-grouped into BMP and non-BMP osteobiologics. For the 10 BMP studies, doses varied from 0.26 to 2.1 mg in 649 patients with fusion rates of 95.3 to 100% at 12 months. For other osteobiologics, each of six studies reported one type of osteobiologic in certain dose/concentration/volume in a total of 580 patients with fusion rates of 6.8 to 96.9% at 12 months. Risk of bias was low in three of the 13 non-randomized (18.75%) and in all the three randomized studies (100%). CONCLUSIONS: Taking into account the inconsistent reporting within available literature, for BMP usage in ACDF, doses lower than 0.7 mg per level can achieve equal successful fusion rates as higher doses, and there is no complication-free dose proved yet. It seems that the lower the dose the lower the incidence of serious complications. As for non-BMP osteobiologics the studies are very limited for each osteobiologic and thus conclusions must be drawn individually and with caution.

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction.

BACKGROUND: Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery. OBJECTIVE: To investigate the association between the GAP score and mechanical complications after ASD surgery. METHODS: Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis. RESULTS: Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023). CONCLUSION: Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool.

The role of radiation therapy in the treatment of spine metastases from hepatocellular carcinoma: a systematic review and meta-analysis.

OBJECTIVE: Spine hepatocellular carcinoma (HCC) metastases severely worsen quality of life and prognosis, with the role of radiotherapy being controversial. The authors systematically reviewed the literature on radiotherapy for spine metastatic HCCs. METHODS: The PubMed, Scopus, Web of Science, and Cochrane databases were searched according to the PRISMA guidelines to include studies of radiotherapy for spine metastatic HCCs. Outcomes, complications, and local control were analyzed with indirect random-effect meta-analyses. RESULTS: The authors included 12 studies comprising 713 patients. The median time interval from diagnosis of HCC to spine metastases was 12 months (range 0-105 months). Most lesions were thoracic (35.9%) or lumbar (24.7%). Radiotherapy was delivered with conventional external-beam (67.3%) or stereotactic (31.7%) techniques. The median dose was 30.3 Gy (range 12.5-52 Gy) in a median of 5 fractions (range 1-20 fractions). The median biologically effective dose was 44.8 Gy10 (range 14.4-112.5 Gy10). Actuarial rates of postradiotherapy pain relief and radiological response were 87% (95% CI 84%-90%) and 70% (95% CI 65%-75%), respectively. Radiation-related adverse events and vertebral fractures had actuarial rates of 8% (95% CI 5%-11%) and 16% (95% CI 10%-23%), respectively, with fracture rates significantly higher after stereotactic radiotherapy (p = 0.033). Fifty-eight patients (27.6%) had local recurrences after a median of 6.8 months (range 0.1-59 months), with pooled local control rates of 61.6% at 6 months and 40.8% at 12 months, and there were no significant differences based on radiotherapy type (p = 0.068). The median survival was 6 months (range 0.1-62 months), with pooled rates of 52.5% at 6 months and 23.4% at 12 months. CONCLUSIONS: Radiotherapy in spine metastatic HCCs shows favorable rates of pain relief, radiological responses, and local control. Rates of postradiotherapy vertebral fractures are higher after high-dose stereotactic radiotherapy.

Percutaneous screw fixation versus open fusion for the treatment of traumatic thoracolumbar fractures: A retrospective case series of 185 Patients with a single-level spinal column injury.

STUDY DESIGN: Retrospective Single-Center Review of Data at a Level 1 Trauma Center. OBJECTIVE: Compare deformity correction and surgical outcomes of percutaneous instrumentation and open fusion in traumatic thoracolumbar fractures. METHODS: In our retrospective study, all patients undergoing elective spine surgery for TL fractures at a Level 1 trauma center between 2000 and 2017 were reviewed. Patients who underwent percutaneous fixation were given the option of hardware removal after the fracture had healed. RESULTS: A total of 185 patients were included in the study, with 109 treated with an open fusion, and 76 with percutaneous fixation. Twenty-five patients in the latter group had the instrumentation removed after the fracture had healed. None of them required reoperation. In the open fusion group 54.1% of patients required a decompressive laminectomy. Percutaneous fixation patients had a shorter operative time (98.3 min vs 214 min, p < 0.0001), shorter length of stay (9.8 days vs 13.5 days, p = 0.04), and less blood loss (68.4 cc vs 691 cc, p < 0.001). They also had a better correction of their traumatic kyphosis after surgery (p = 0.005). CONCLUSION: Percutaneous fixation is a valuable option for the treatment of TL fractures in cases without evidence of neural compression. It is still unclear whether hardware removal helps prevent adjacent segment degeneration. Percutaneous fixation could allow for better reduction of the fracture with improvement of postoperative alignment.

Penetrating spinal cord injury: a systematic review and meta-analysis of clinical features and treatment outcomes.

OBJECTIVE: To systematically review the literature on penetrating spinal cord injury (PSCI) and evaluate current management strategies, their impact on patient functional outcomes, and treatment complications. METHODS: PubMed, Scopus, and Cochrane were searched based on the Preferred Reporting Items for Systematic-Reviews and Meta-Analyses (PRISMA) guidelines to include studies on penetrating spinal cord injury (PSCI). RESULTS: We included 10 articles comprising 1754 cases of PSCI. Mean age was 19.2 years (range, 16-70), and most patients were male (89.9%). Missile spinal cord injury (MSCI) was the most common type, affecting 1623 patients (92.6%), while non-missile spinal cord injury (NMSCI) accounted for only 131 cases (7.4%). Gunshots were the most common cause of MSCI, representing 87.2%, while knife stabs were the most common cause of NMSCI, representing 72.5%. A total of 425 patients (28.0%) underwent surgical intervention, and 1094 (72.0%) underwent conservative management. The conservative group had a higher rate of complete spine cord injury compared with the surgical group (61.5% vs. 49.2; p < 0.001). Although surgery yielded a higher score improvement rate compared with the conservative management (41.5% vs. 20.5%, p < 0.001), neither treatment strategy displayed superiority in improving neurological outcomes for neither complete SCIs (OR:0.7, 95% CI, 0.3-1.64; I2 = 44%, p = 0.13) nor for incomplete SCIs (OR:1.15, 95% CI, 0.64-2,06; I2 = 40%, p = 0.12). CONCLUSION: Surgical and conservative management strategies proved to be equally effective on PSCI, irrespective of injury severity. Therefore, tailored treatment strategies for each patient and careful surgical selection is advised.

Intradural Cauda Equina Metastases: A Systematic Review of Clinico-radiological Features, Management, and Treatment Outcomes.

BACKGROUND/AIM: Intradural cauda equina metastases (ICEM) are rare tumors that reduce functional status. Surgery and radiation are feasible and effective treatments but may have debilitating complications. We systematically reviewed the literature on ICEMs. MATERIALS AND METHODS: PubMed, Scopus, Web of Science, and Cochrane were searched for studies reporting clinical data of patients with ICEMs. Clinical characteristics, management strategies, and treatment outcomes were analyzed. RESULTS: We included 40 studies comprising 123 patients. Median age was 57 years. The most frequent primary tumors were lung (18.7%), breast (13%), and renal carcinomas (11.4%). Median time from primary tumor diagnosis to ICEMs' presentation was 36 months. The most common presenting symptoms were lower back pain (74%) and motor deficits (62.6%), with acute cauda equina syndrome documented in 36 patients (29.3%). Most lesions were diagnosed at magnetic resonance imaging (56.9%) or computed tomography myelography (32.5%). All cases were treated with decompressive laminectomy and tumor resection, with partial resection (82.1%) more often than complete (15.4%). Adjuvant radiotherapy (83.7%) and/or chemotherapy (10.6%) were often administered. Most patients experienced post-treatment symptom improvement (86.2%) and favorable radiological response (82.9%). ICEM recurrences were reported in 4 cases (8.5%) with median local tumor control of 7 months. At last follow-up, most patients were dead (62.9%) with median overall-survival of 10 months. CONCLUSION: Patients with ICEMs have poor prognoses and significant tumor burden. Surgery and locoregional radiotherapy may offer optimal clinical and radiological outcomes but have a limited role in improving local tumor control and overall survival.

Radiofrequency ablation for spinal osteoid osteoma: A systematic review of safety and treatment outcomes.

AIM: We sought to systematically assess and summarize the available literature on the clinical outcomes and complications following radiofrequency ablation (RFA) for painful spinal osteoid osteoma (OO). METHODS: PubMed, Scopus, and CENTRAL databases were searched in accordance with PRISMA guidelines. Studies with available data on safety and clinical outcomes following RFA for spinal OO were included. RESULTS: In the 14 included studies (11 retrospective; 3 prospective), 354 patients underwent RFA for spinal OO. The mean ages ranged from 16.4 to 28 years (Females = 31.3%). Lesion diameters ranged between 3 and 20 mm and were frequently seen in the posterior elements in 211/331 (64%) patients. The mean distance between OO lesions and neural elements ranged between 1.7 and 7.4 mm. The estimated pain reduction on the numerical rating scale was 6.85/10 (95% confidence intervals [95%CI] 4.67-9.04) at a 12-24-month follow-up; and 7.29/10 (95% CI 6.67-7.91) at a >24-month follow-up (range 24-55 months). Protective measures (e.g., epidural air insufflation or neuroprotective sterile water infusion) were used in 43/354 (12.1%) patients. Local tumor progression was seen in 23/354 (6.5%) patients who were then successfully re-treated with RFA or open surgical resection. Grade I-II complications such as temporary limb paresthesia and wound dehiscence were reported in 4/354 (1.1%) patients. No Grade III-V complications were reported. CONCLUSION: RFA demonstrated safety and clinical efficacy in most patients harboring painful spinal OO lesions. However, further prospective studies evaluating these outcomes are warranted.

Evaluating the Optimal Management of Inoperable Giant Cell Tumors of the Spine: A Systematic Review and Meta-Analysis.

BACKGROUND: Surgical resection remains the preferred treatment in spine giant cell tumors (SGCTs), but it is not always feasible. Conservative strategies have been studied for inoperable cases. We systematically reviewed the literature on inoperable SGCTs treated with denosumab, radiotherapy or selective arterial embolization (SAE). METHODS: PubMed, Scopus, Web-of-Science, Ovid-EMBASE, and Cochrane were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include studies of inoperable SGCTs treated with denosumab, radiotherapy or SAE. Treatment outcomes were analyzed and compared with a random-effect model meta-analysis. RESULTS: Among the 17 studies included, 128 patients received denosumab, 59 radiotherapy, and 43 SAE. No significant differences in baseline patient characteristics were found between the three groups. All strategies were equally effective in providing symptom improvement (p = 0.187, I2 = 0%) and reduction in tumor volume (p = 0.738, I2 = 56.8%). Rates of treatment-related complications were low (denosumab: 12.5%; radiotherapy: 8.5%; SAE: 18.6%) and comparable (p = 0.311, I2 = 0%). Patients receiving denosumab had significantly lower rates of local tumor recurrence (10.9%) and distant metastases (0%) compared to patients receiving radiotherapy (30.5%; 8.5%) or SAE (35.6%; 7%) (p = 0.003, I2 = 32%; p = 0.002, I2 = 47%). Denosumab was also correlated with significantly higher overall survival rates at 18 months (99.2%) and 24 months (99.2%) compared to radiotherapy (91.5%; 89.6%) and SAE (92.5%; 89.4%) (p = 0.019, I2 = 8%; p = 0.004, I2 = 23%). Mortality was higher in patients receiving SAE (20.9%) or radiotherapy (13.6%) compared to denosumab (0.8%) (p < 0.001), but deaths mostly occurred for unrelated diseases. CONCLUSIONS: Denosumab, radiotherapy, and SAE are safe and effective for inoperable SGCTs. Clinical and radiological outcomes are mostly comparable, but denosumab may provide superior tumor control.

Primary central nervous system sarcomas in adults: A systematic review.

BACKGROUND: Primary central nervous system (CNS) sarcomas represent a heterogeneous group of rare neoplasms with unclear etiology. Available data on clinical characteristics, treatment strategies, and survival are scarce. We comprehensively reviewed management strategies and outcomes of primary CNS sarcomas in adults. METHODS: PubMed, Scopus, and Cochrane were search following the PRISMA guidelines to include studies on primary CNS sarcomas in adults. Clinical features, management strategies, and survival were analyzed. RESULTS: We included 9 studies comprising 78 patients. Primary CNS sarcomas were mostly intracranial (87.2%), frequently located in the parietal (17.9%), frontal (14.1%), and temporal (14.1%) lobes. Spinal CNS sarcomas were found in 10 patients (12.8%). The most common tumor histology were fibrosarcoma (16.7%), intracranial synovial sarcoma (12.8%), extraosseous mesenchymal chondrosarcoma (11.5%), perivascular sarcoma (11.5%), reticulum cell sarcoma (11.5%), and myeloid sarcoma (9%). Partial resection (57.7%) was preferred over complete resection (42.3%), and 43 patients (55.1%) received adjuvant treatments: radiotherapy (51.3%) and/or systemic chemotherapy (20.5%). 21 patients experienced CNS sarcomas recurrences, with a median progression-free survival of 9 months (range, 4-48). At last follow-up, 60 patients (76.9%) were dead, with a median overall survival of 9 months (0.1-396). Overall survival was significantly longer in patients with fibrosarcoma (p = 0.001). CONCLUSION: Surgical resection coupled with adjuvant chemotherapy or radiation has historically been the cornerstone treatment for CNS sarcoma but showed poor local control and dismal survival. A better understanding of the CNS sarcoma microenvironment may favor the development of tailored strategies aimed at improving survival.

Primary Paraganglioma of the Spine: A Systematic Review of Clinical Features and Surgical Management in Cauda Equina versus Non-Cauda Equina Lesions.

BACKGROUND: Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas. METHODS: PubMed, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiologic features, treatments, and outcomes were analyzed and compared between cauda equina versus non-cauda equina tumors. RESULTS: We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85 years). The most frequent symptoms were lower back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5 cm (range, 0.5-13.0 cm). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Posttreatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0 months), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda equina versus non-cauda equina tumors. CONCLUSIONS: Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.

Posterior epidural intervertebral disc migration and sequestration: A systematic review.

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

Leptomeningeal Metastases of the Spine: A Systematic Review.

BACKGROUND/AIM: Leptomeningeal metastases (LMs) of the spine have complex management. We reviewed the literature on spine LMs. MATERIALS AND METHODS: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of spine LMs. RESULTS: We included 46 studies comprising 72 patients. The most frequent primary tumors were lung (19.4%) and breast cancers (19.4%). Median time from primary tumors was 12 months (range=0-252 months). Cauda equina syndrome occurred in 34 patients (48.6%). Nodular spine LMs (63.6%) were more frequent. Concurrent intracranial LMs were present in 27 cases (50.9%). Cerebrospinal fluid cytology was positive in 31 cases (63.6%). Cases were managed using palliative steroids (73.6%) with locoregional radiotherapy (55.6%) chemotherapy (47.2%), or decompressive laminectomy (8.3%). Post-treatment symptom improvement (32%) and favorable radiological response (28.3%) were not different based on treatment (p=0.966; p=0.727). Median overall-survival was 3 months (range=0.3-60 months), not significantly different between radiotherapy and chemotherapy (p=0.217). CONCLUSION: Spine LMs have poor prognoses. Radiotherapy, chemotherapy, and surgery are only palliative, as described for intracranial LMs.

Percutaneous image-guided cryoablation of spinal metastases: A systematic review.

Percutaneous cryoablation (PCA) is a minimally invasive technique that has been recently used to treat spinal metastases with a paucity of data currently available in the literature. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Prospective or retrospective studies concerning metastatic spinal neoplasms treated with current generation PCA systems and with available data on safety and clinical outcomes were included. In the 8 included studies (7 retrospective, 1 prospective), a total of 148 patients (females = 63%) underwent spinal PCA. Tumors were located in the cervical (3/109 [2.8%], thoracic (74/109 [68.8%], lumbar (37/109 [33.9%], and sacrococcygeal (17/109 [15.6%] regions. Overall, 187 metastatic spinal lesions were treated. Thermo-protective measures (e.g., carbo-/hydro-dissection, thermocouples) were used in 115/187 [61.5%] procedures. For metastatic spinal tumors, the pooled mean difference (MD) in pain scores from baseline on the 0-10 numeric rating scale was 5.03 (95% confidence interval [CI]: 4.24 to 5.82) at a 1-month follow-up and 4.61 (95% CI: 3.27 to 5.95) at the last reported follow-up (range 24-40 weeks in 3/4 studies). Local tumor control rates ranged widely from 60% to 100% at varying follow-ups. Grade I-II complications were reported in 9/148 [6.1%] patients and grade III-V complications were reported in 3/148 [2.0%]) patients. PCA, as a stand-alone or adjunct modality, may be a viable therapy in appropriately selected patients with painful spinal metastases who were traditionally managed with open surgery and/or radiation therapy.

Coccygectomy for refractory coccygodynia: a systematic review and meta-analysis.

PURPOSE: We sought to systematically assess and summarize the available literature on outcomes following coccygectomy for refractory coccygodynia. METHODS: PubMed, Scopus, and Cochrane Library databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data concerning patient demographics, validated patient reported outcome measures (PROMs) for pain relief, disability outcomes, complications, and reoperation rates were extracted and analyzed. RESULTS: A total of 21 studies (18 retrospective and 3 prospective) were included in the quantitative analysis. A total of 826 patients (females = 75%) received coccygectomy (720 total and 106 partial) for refractory coccygodynia. Trauma was reported as the most common etiology of coccygodynia (56%; n = 375), followed by idiopathic causes (33%; n = 221). The pooled mean difference (MD) in pain scores from baseline on a 0-10 scale was 5.03 (95% confidence interval [CI]: 4.35 to 6.86) at a 6-12 month follow-up (FU); 5.02 (95% CI: 3.47 to 6.57) at > 12-36 months FU; and 5.41 (95% CI: 4.33 to 6.48) at > 36 months FU. The MCID threshold for pain relief was surpassed at each follow-up. Oswestry Disability Index scores significantly improved postoperatively, with a pooled MD from baseline of - 23.49 (95% CI: - 31.51 to - 15.46), surpassing the MCID threshold. The pooled incidence of complications following coccygectomy was 8% (95% CI: 5% to 12%), the most frequent of which were surgical site infections and wound dehiscence. The pooled incidence of reoperations was 3% (95% CI: 1% to 5%). CONCLUSION: Coccygectomy represents a viable treatment option in patients with refractory coccygodynia.

Metal Hypersensitivity and Complex Regional Pain Syndrome After Bilateral Total Knee Arthroplasty: A Case Report.

CASE: A 38-year-old man underwent bilateral total knee arthroplasty (TKA) and subsequently developed diffuse pain, swelling, and an eczematous rash that spread throughout his body. Despite various pharmacological regimens, sympathetic blocks, aggressive physical therapy, and further knee revisions, the patient's symptoms progressed over a period of 2 years. An in vitro memory lymphocyte immuno-stimulation assay test demonstrated reactivity to nickel after which bilateral revision TKAs with oxidized zirconium alloys resulted in symptomatic improvement. CONCLUSION: Metal hypersensitivity should be considered after the exclusion of infection; however, the concurrent development of complex regional pain syndrome may mask the clinical presentation.

Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis.

OBJECTIVE: Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities. METHODS: We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms. RESULTS: A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324). CONCLUSIONS: Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.

Iodine-125 radioactive seed brachytherapy as a treatment for spine and bone metastases: A systematic review and meta-analysis.

AIM: To evaluate the analgesic efficacy, safety, and local tumor control of iodine-125 (125I) seed brachytherapy (BT) for the management of spine and bone metastases. METHODS: A systematic literature search was conducted using PubMed, the Cochrane Library, and Scopus databases. Data regarding patient demographics, tumor characteristics, procedural parameters, and clinical outcomes were extracted and analyzed. RESULTS: Fourteen studies (7 prospective, 7 retrospective) were included, accounting for 689 patients, in our review. Analgesic efficacy was assessed at baseline and various postoperative time points. Significant improvement in pain was noted at 4- and 24-week follow-ups (p < 0.01). Interestingly, all studies that combined 125I seed BT with cement augmentation reported relatively higher levels of pain reduction (mean pain reduction ≥4 points) as compared to the studies which applied 125I seed BT as a stand-alone therapy (mean pain reduction ≥2 points), at the last follow-up. Local tumor control rates ranged widely from 14% to 100% at varying follow-ups. Median overall survival ranged between 10 months and 25 months. The overall complication rate was 19% (130/689) and mainly included minor subcutaneous hemorrhage, fever, myelosuppression, and seed displacement. Metrics assessing performance and quality of life demonstrated significant improvements from baseline to posttreatment. CONCLUSION: 125I seed BT, alone or in conjunction with cement augmentation, may be a viable salvage therapy in appropriately selected patients. However, further studies are needed to analyze the long-term efficacy of this intervention as a palliative and curative modality.

Primary and radiation induced skull base osteosarcoma: a systematic review of clinical features and treatment outcomes.

PURPOSE: We aim to systematically review and summarize the demographics, clinical features, management strategies, and clinical outcomes of primary and radiation-induced skull-base osteosarcoma (SBO). METHODS: PubMed, Scopus, and Cochrane databases were used to identify relevant articles. Papers including SBO cases and sufficient clinical outcome data were included. A comprehensive clinical characteristic review and survival analysis were also conducted. RESULTS: Forty-one studies describing 67 patients were included. The median age was 31 years (male = 59.7%). The middle skull-base was most commonly involved (52.7%), followed by anterior (34.5%) and posterior (12.7%) skull-base. Headache (27%), exophthalmos (18%), and diplopia (10%) were common presenting symptoms. Sixty-eight percent of patients had primary SBO, while 25% had radiation-induced SBO. Surgery was the main treatment modality in 89% of cases. Chemotherapy was administered in 65.7% and radiotherapy in 50%. Median progression-free survival (PFS) was 12 months, and the overall 5-year survival was 22%. The five-year survival rates of radiation-induced SBO and primary SBO were 39% and 16%, respectively (P < 0.05). CONCLUSION: SBO is a malignant disease with poor survival outcomes. Surgical resection is the primary management modality, in conjunction with chemotherapy and radiotherapy. Radiation-induced SBO has a superior survival outcome as compared to its primary counterpart. Complete surgical resection showed a statistically insignificant survival benefit as compared to partial resection.

Microwave Ablation as a Treatment for Spinal Metastatic Tumors: A Systematic Review.

BACKGROUND: Microwave ablation (MWA) is a novel technique that offers several potential advantages over existing ablation systems, which include production of larger ablation zones, shorter procedural times, and more effective heating through high impedance tissues such as bone. METHODS: A systematic review was performed using inclusion criteria defined as follows: 1) metastatic spinal tumors treated with open or percutaneous MWA alone or in combination with other treatments, 2) available data on pain palliation and/or local tumor control, and 3) retrospective or prospective studies with at least 1 patient. RESULTS: A total of 156 patients harboring 196 spinal lesions underwent MWA in the 8 included studies. Most studies employed the use of additional interventions, which included minimally invasive open surgery with pedicle screw fixation, traditional open surgical intervention, and cement augmentation. Despite the variability in time intervals for pain assessment, postoperative pain scores decreased considerably in both percutaneous and open MWA studies. No evidence of tumor progression was additionally seen in >80% of patients at the last follow-up across 5 studies. Complications were reported in 6.5% of all patients who underwent percutaneous MWA and in 12.2% of patients who underwent open MWA. CONCLUSIONS: This review showed that MWA can be effective in achieving analgesia for up to 6 months in select cases, although most procedures were performed in combination with augmentation and/or open surgery. Local tumor control was additionally successful in most patients, suggestive of a potential curative role for MWA.