Cervical kyphosis after posterior cervical laminectomy with and without fusion.

BACKGROUND: Cervical posterior instrumentation and fusion is often performed to avoid post-laminectomy kyphosis. However, larger comparative analyses of cervical laminectomy with or without fusion are sparse. METHODS: A retrospective, two-center, comparative cohort study included patients after stand-alone dorsal laminectomy with (n = 91) or without (n = 46) additional fusion for degenerative cervical myelopathy with a median follow-up of 59 (interquartile range (IQR) 52) months. The primary outcome was the C2-7 Cobb angle and secondary outcomes were Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scale, revision rates, T1 slope and C2-7 sagittal vertical axis (C2-7 SVA) at final follow-up. Logistic regression analysis adjusted for potential confounders (i.e. age, operated levels, and follow-up). RESULTS: Preoperative C2-7 Cobb angle and T1 slope were higher in the laminectomy group, while the C2-7 SVA was similar. The decrease in C2-7 Cobb angle from pre- to postoperatively was more pronounced in the laminectomy group (- 6° (IQR 20) versus -1° (IQR 7), p = 0.002). When adjusting for confounders, the decrease in C2-7 Cobb angle remained higher in the laminectomy group (coefficient - 12 (95% confidence interval (CI) -18 to -5), p = 0.001). However, there were no adjusted differences for postoperative NDI (- 11 (- 23 to 2), p = 0.10), mJOA, revision rates, T1 slope and C2-7 SVA. CONCLUSION: Posterior cervical laminectomy without fusion is associated with mild loss of cervical lordosis of around 6° in the mid-term after approximately five years, however without any clinical relevance regarding NDI or mJOA in well-selected patients (particularly in shorter segment laminectomies of < 3 levels).

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study.

BACKGROUND: The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries. METHODS: Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors. RESULTS: The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs. CONCLUSIONS: This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Effect of reversal of residual neuromuscular blockade on the amplitude of motor evoked potentials: a randomized controlled crossover study comparing sugammadex and placebo.

PURPOSE: To compare the amplitude changes in motor evoked potentials (MEP) with reversal of residual neuromuscular blockade using sugammadex or placebo in patients with cervical myelopathy. METHODS: In this prospective randomized double-blind, placebo-controlled crossover trial, 38 patients with cervical myelopathy undergoing posterior cervical decompression and fusion were randomized to either sugammadex (2mg/kg) or placebo. The primary outcome measure was the increase in amplitude of the MEP in the first dorsal interossei (FDI) muscle at 3 min. Mann-Whitney U test was used to analyze the primary outcome measure. RESULTS: There was a significant increase in the amplitude of MEP at 3 min with sugammadex when compared to placebo group. The median (IQR) increase in MEP amplitude (µV) at 3 min from the left FDI in sugammadex and placebo group was 652.9 (142:1650) and 20.6 (-183.5:297.5) (p <0.001), respectively. Corresponding values from right FDI were 2153.4 (1400:4536.8) and 55(-65.2:480.8) (p=<0.001). CONCLUSION: Our study showed that there was a 200% increase in the MEP amplitude in the first dorsal interosseous muscle at 3 min following reversal of residual neuromuscular blockade with sugammadex. By ensuring that maximal MEP amplitude is recorded at baseline, early commencement of neuromonitoring can be achieved. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: The study was registered at http://clinicaltrials.gov , ID NCT03087513, Feb 5th 2018.

How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database.

BACKGROUND: The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database. METHODS: The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed. RESULTS: A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%. CONCLUSION: We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.

Emergent and Urgent Transfers to Neurosurgical Centers in Ontario.

Critically ill neurosurgical patients require expedient access to neurosurgical centers (NC) to improve outcome. In regionalized health systems patients are often initially evaluated at a non-neurosurgical center (NNC) and are subsequently transferred to a NC using air or ground vehicles. We sought to identify barriers to accessing a NC for critically ill patients by analyzing interfacility transfer times and referral patterns in the province of Ontario. A retrospective observational analysis was undertaken. The cohort included patients in Ontario with emergent and urgent neurologic pathologies who underwent transfer from a NNC to NC between January 1, 2011 and December 31, 2013. Timing, clinical, and geographic data were collected for each transfer. We identified 1103 emergent/urgent transfers. The median transfer time to a NC was 3.4 h (IQR -2.2, 3.8) and varied by the geographic region of origin. A total of 17% of the patients bypassed a closer NC during transfer to their destination NC. Transfers that bypassed a closer NC travelled further (101 miles vs. 296 miles, p < 0.001), took longer (3.1 h vs. 3.9 h, p < 0.001), and in some regions were associated with a higher risk of in-transit clinical decline (3.0% vs. 8.3%, p < 0.05) when compared with transfers that ended at the closest NC. Regionalization of neurosurgical services in Ontario has led to heavy reliance upon patient transfers to maintain continuity of care. Access to a NC varied across the province, which may represent regional differences in neurosurgical bed availability, resource limitations at smaller NCs, or environmental factors. Our descriptions of referral patterns and transport times can guide health system planning in Ontario and similar jurisdictions in the United States and Canada.

Clinical and pathological outcomes after resection of intramedullary spinal cord tumors: a single-institution case series.

OBJECTIVE The objective of this study was to identify clinically relevant predictors of progression-free survival and functional outcomes in patients who underwent surgery for intramedullary spinal cord tumors (ISCTs). METHODS An institutional spinal tumor registry and billing records were reviewed to identify adult patients who underwent resection of ISCTs between 1993 and 2014. Extensive data were collected from patient charts and operative notes, including demographic information, extent of resection, tumor pathology, and functional and oncological outcomes. Survival analysis was used to determine important predictors of progression-free survival. Logistic regression analysis was used to evaluate the association between an "optimal" functional outcome on the Frankel or McCormick scale at 1-year follow-up and various clinical and surgical characteristics. RESULTS The consecutive case series consisted of 63 patients (50.79% female) who underwent resection of ISCTs. The mean age of patients was 41.92 ± 14.36 years (range 17.60-75.40 years). Complete microsurgical resection, defined as no evidence of tumor on initial postoperative imaging, was achieved in 34 cases (54.84%) of the 62 patients for whom this information was available. On univariate analysis, the most significant predictor of progression-free survival was tumor histology (p = 0.0027). Patients with Grade I/II astrocytomas were more likely to have tumor progression than patients with WHO Grade II ependymomas (HR 8.03, 95% CI 2.07-31.11, p = 0.0026) and myxopapillary ependymomas (HR 8.01, 95% CI 1.44-44.34, p = 0.017). Furthermore, patients who underwent radical or subtotal resection were more likely to have tumor progression than those who underwent complete resection (HR 3.46, 95% CI 1.23-9.73, p = 0.018). Multivariate analysis revealed that tumor pathology was the only significant predictor of tumor progression. On univariate analysis, the most significant predictors of an "optimal" outcome on the Frankel scale were age (OR 0.94, 95% CI 0.89-0.98, p = 0.0062), preoperative Frankel grade (OR 4.84, 95% CI 1.33-17.63, p = 0.017), McCormick score (OR 0.22, 95% CI 0.084-0.57, p = 0.0018), and region of spinal cord (cervical vs conus: OR 0.067, 95% CI 0.012-0.38, p = 0.0023; and thoracic vs conus: OR 0.015: 95% CI 0.001-0.20, p = 0.0013). Age, tumor pathology, and region were also important predictors of 1-year McCormick scores. CONCLUSIONS Extent of tumor resection and histopathology are significant predictors of progression-free survival following resection of ISCTs. Important predictors of functional outcomes include tumor histology, region of spinal cord in which the tumor is present, age, and preoperative functional status.

Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort.

Introduction Metastatic spinal cancer is a common condition that may lead to spinal instability, pain and paralysis. In the 1980s, surgery was discouraged because results showed worse neurological outcomes and pain compared with radiotherapy alone. However, with the advent of modern imaging and spinal stabilisation techniques, the role of surgery has regained centre stage, though few studies have assessed quality of life and functional outcomes after surgery. Objective We investigated whether surgery provides sustained improvement in quality of life and pain relief for patients with symptomatic spinal metastases by analysing the largest reported surgical series of patients with epidural spinal metastases. Methods A prospective cohort study of 922 consecutive patients with spinal metastases who underwent surgery, from the Global Spine Tumour Study Group database. Pre- and post-operative EQ-5D quality of life, visual analogue pain score, Karnofsky physical functioning score, complication rates and survival were recorded. Results Quality of life (EQ-5D), VAS pain score and Karnofsky physical functioning score improved rapidly after surgery and these improvements were sustained in those patients who survived up to 2 years after surgery. In specialised spine centres, the technical intra-operative complication rate of surgery was low, however almost a quarter of patients experienced post-operative systemic adverse events. Conclusion Surgical treatment for spinal metastases produces rapid pain relief, maintains ambulation and improves good quality of life. However, as a group, patients with cancer are vulnerable to post-operative systemic complications, hence the importance of appropriate patient selection.

Effect of superficial cervical plexus block on postoperative quality of recovery after anterior cervical discectomy and fusion: a randomized controlled trial.

PURPOSE: Spine surgeries are increasingly being performed as a day or short-stay surgery programs. Peripheral nerve block provide site-specific pain relief with few side effects, thereby reducing surgical stress and enhancing quality of recovery. The aim of our study was to determine the effect of a superficial cervical plexus block (SCPB) on postoperative quality of recovery and analgesia in patients undergoing elective anterior cervical discectomy and fusion (ACDF). METHODS: After Research Ethics Board approval, we enrolled adults (> 18 yr) scheduled for elective single- or two-level ACDF in this randomized double-blind clinical trial. Participants were randomized to receive either a SCPB (0.25% bupivacaine, 10 mL) or No Block. The primary outcome measure was the quality of recovery at 24 hr, measured using the 40-item quality of recovery questionnaire (QoR-40). In addition, comparisons between groups were also made for postoperative opioid consumption and discharge times. RESULTS: Forty-six patients were randomized to receive either a SCPB block (n = 23) or No Block (n = 23). Median [interquartile range] aggregated global QoR-40 scores at 24 hr were significantly greater in the SCPB group, indicating good quality of recovery compared with the No Block group (179 [116-195] vs 157 [97-196], respectively; median difference, 22; 95% confidence interval [CI], 7 to 34; P = 0.002]. There were no differences between the SCPB and the No Block group with regard to mean (standard deviation) postoperative opioid consumption at 24 hr [22.9 (13.6) mg vs 24.6 (9.5) mg, respectively; mean difference 1.7; 95% CI, -5.2 to 8.7; P = 0.620] and the number of patients discharged within 24 hr (15 vs 12, respectively; P = 0.550). CONCLUSION: We showed that preoperative SCPB is an effective strategy for improving the early quality of recovery in patients undergoing single- or two-level ACDF. Nevertheless, there was no impact on opioid consumption or discharge times. This trial was registered at www.clinicaltrials.gov (NCT01662219).

Riluzole for Degenerative Cervical Myelopathy: A Secondary Analysis of the CSM-PROTECT Trial.

Importance: The modified Japanese Orthopaedic Association (mJOA) scale is the most common scale used to represent outcomes of degenerative cervical myelopathy (DCM); however, it lacks consideration for neck pain scores and neglects the multidimensional aspect of recovery after surgery. Objective: To use a global statistical approach that incorporates assessments of multiple outcomes to reassess the efficacy of riluzole in patients undergoing spinal surgery for DCM. Design, Setting, and Participants: This was a secondary analysis of prespecified secondary end points within the Efficacy of Riluzole in Surgical Treatment for Cervical Spondylotic Myelopathy (CSM-PROTECT) trial, a multicenter, double-blind, phase 3 randomized clinical trial conducted from January 2012 to May 2017. Adult surgical patients with DCM with moderate to severe myelopathy (mJOA scale score of 8-14) were randomized to receive either riluzole or placebo. The present study was conducted from July to December 2023. Intervention: Riluzole (50 mg twice daily) or placebo for a total of 6 weeks, including 2 weeks prior to surgery and 4 weeks following surgery. Main Outcomes and Measures: The primary outcome measure was a difference in clinical improvement from baseline to 1-year follow-up, assessed using a global statistical test (GST). The 36-Item Short Form Health Survey Physical Component Score (SF-36 PCS), arm and neck pain numeric rating scale (NRS) scores, American Spinal Injury Association (ASIA) motor score, and Nurick grade were combined into a single summary statistic known as the global treatment effect (GTE). Results: Overall, 290 patients (riluzole group, 141; placebo group, 149; mean [SD] age, 59 [10.1] years; 161 [56%] male) were included. Riluzole showed a significantly higher probability of global improvement compared with placebo at 1-year follow-up (GTE, 0.08; 95% CI, 0.00-0.16; P = .02). A similar favorable global response was seen at 35 days and 6 months (GTE for both, 0.07; 95% CI, -0.01 to 0.15; P = .04), although the results were not statistically significant. Riluzole-treated patients had at least a 54% likelihood of achieving better outcomes at 1 year compared with the placebo group. The ASIA motor score and neck and arm pain NRS combination at 1 year provided the best-fit parsimonious model for detecting a benefit of riluzole (GTE, 0.11; 95% CI, 0.02-0.16; P = .007). Conclusions and Relevance: In this secondary analysis of the CSM-PROTECT trial using a global outcome technique, riluzole was associated with improved clinical outcomes in patients with DCM. The GST offered probability-based results capable of representing diverse outcome scales and should be considered in future studies assessing spine surgery outcomes.

Postoperative C5 Palsy after Anterior or Posterior Decompression for Degenerative Cervical Myelopathy: A Subgroup Analysis of the Multicenter, Prospective, Randomized, Phase III, CSM-Protect Clinical Trial.

STUDY DESIGN: Retrospective cohort study of prospectively accrued data. OBJECTIVE: To evaluate a large, prospective, multicentre dataset of surgically-treated DCM cases on the contemporary risk of C5 palsy with surgical approach. SUMMARY OF BACKGROUND DATA: The influence of surgical technique on postoperative C5 palsy after decompression for degenerative cervical myelopathy (DCM) is intensely debated. Comprehensive analyses are needed using contemporary data and accounting for covariates. METHODS: Patients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012, to May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy. RESULTS: A total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients that underwent posterior decompression compared to anterior decompression (11.26% vs. 3.03%, P=0.008). After multivariable regression, posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy (P=0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches. CONCLUSION: The odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM. LEVEL OF EVIDENCE: Therapeutic Level II.

Spontaneous intracranial hypotension due to CSF-venous fistula: Evaluation of renal accumulation of contrast following decubitus myelography and maintained decubitus CT to improve fistula localization.

PURPOSE: Presented here is a strategy of sequential lateral decubitus digital subtraction myelography (LDDSM) followed closely by lateral decubitus CT (LDCT) to facilitate cerebrospinal fluid (CSF)-venous fistula (CVF) localization. MATERIALS AND METHODS: This is a retrospective analysis of patients referred to our institution for evaluation of CSF leak. Patients with Type 1 and Type 2 leaks, and those not displaying MR brain stigmata of intracranial hypotension were excluded. All patients underwent consecutive LDDSM and LDCT. If the CVF was not localized on the first LDDSM-LDCT pair the patient returned for contralateral examinations. Images were reviewed for CVF and for accumulation of contrast within the renal pelvises expressed as a renal pelvis contrast score (RPCS) in Hounsfield units (HU). RESULTS: Twenty-two patients were included in this study. In 21 of 22 patients (95%) a CVF was identified yielding an RPCS for the LDDSM-LDCT pair ipsilateral to the CVF ranging from 71 to 423 with an average of 146 HU. An RPCS of the negative side LDDSM-LDCT pair contralateral to a CVF was available in 8 patients and averaged 51 HU. In 4 patients the initial bilateral LDDSM-LDCT pairs did not reveal the location of the CVF however in 3 of these 4 cases the CVF was revealed on a third LDDSM repeated ipsilateral to the higher RPCS. CONCLUSION: The strategy of sequential LDDSM-LDCT coupled with evaluation of renal accumulation of contrast agent appears to improve the rate of CVF localization and warrants further evaluation.

Clinical outcomes and revision rates following four-level anterior cervical discectomy and fusion.

Studies on outcomes after four-level anterior cervical discectomy and fusion (ACDF) are limited in the literature. The purpose of this study was to report on clinical outcomes and revision rates following four-level ACDF. Patients operated with four-level ACDF were identified in a prospectively accrued single institution database. Outcome scores included the Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for neck and arm pain. Reoperation rates were determined. Any complications were identified from a review of the medical records. Twenty-eight patients with a minimum of 12 months follow up were included in the analysis. The mean age at surgery was 58.5 years. The median radiographic follow up time was 23 (IQR = 16-31.25) months. Cervical lordosis was significantly improved postoperatively (- 1 to - 13, p < 0.001). At the median 24 (IQR = 17.75-39.50) months clinical follow up time, there was a significant improvement in the NDI (38 to 28, p = 0.046) and VAS for neck pain scores (5.1 to 3, p = 0.012). The most common perioperative complication was transient dysphagia (32%) followed by hoarseness (14%). Four (14%) patients required revision surgery at a median 11.5 (IQR = 2-51) months postoperatively. The results of this study indicate that patients who undergo four-level ACDF have a significant improvement in clinical outcomes at median 24 months follow up. Stand-alone four-level ACDF is a valid option for the management of complex cervical degenerative conditions.

Preoperative Heart Rate Variability Predicts Postinduction Hypotension in Patients with Cervical Myelopathy: A Prospective Observational Study.

Background: Autonomic dysfunction, commonly seen in patients with cervical myelopathy, may lead to a decrease in blood pressure intraoperatively. Objective: The aim of our study is to determine if changes in Heart rate variability (HRV) could predict hypotension after induction of anesthesia in patients with cervical myelopathy undergoing spine surgery. Methods and Material: In this prospective observational study, 47 patients with cervical myelopathy were included. Five-minute resting ECG (5 lead) was recorded preoperatively and HRV of very low frequency (VLF), low frequency (LF), and high frequency (HF) spectra were calculated using frequency domain analysis. Incidence of hypotension (MAP <80 mmHg, lasting >5 min) and the number of interventions (40 mcg of phenylephrine or 5 mg of ephedrine) required to treat the hypotension during the period from induction to surgical incision were recorded. HRV indices were compared between the hypotension group and the stable group. Results: The incidence of hypotension after induction was 74.4% (35/47) and the median (IQR) interventions needed to treat hypotension was 2 (0.5-6). Patients who experienced hypotension had lower HF power and higher LF-HF ratios. A LF/HF >2.5 indicated postinduction hypotension likely. There was a correlation between increasing LF-HF ratio and the number of interventions that needs to maintain the MAP above 80 mmHg. Conclusion: HF power was lower and LF-HF ratio was higher in patients with cervical myelopathy who developed postinduction hypotension. Hence, preoperative HRV analysis can be useful to identify patients with cervical myelopathy who are at risk of post-induction hypotension.

Recent advances and new discoveries in the pipeline of the treatment of primary spinal tumors and spinal metastases: a scoping review of registered clinical studies from 2000 to 2020.

The field of spinal oncology has substantially evolved over the past decades. This review synthesizes and appraises what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms. This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February 2000 to December 2020. The terms "spinal cord tumor," "spinal metastasis," and "metastatic spinal cord compression" were used. Of the 174 registered clinical studies on primary spinal tumors and spinal metastasis, most of the clinical studies registered in this American registry were interventional studies led by single institutions in North America (n = 101), Europe (n = 43), Asia (n = 24), or other continents (n = 6). The registered clinical studies mainly focused on treatment strategies for spinal neoplasms (90.2%) that included investigating stereotactic radiosurgery (n = 33), radiotherapy (n = 21), chemotherapy (n = 20), and surgical technique (n = 11). Of the 69 completed studies, the results from 44 studies were published in the literature. In conclusion, this review highlights the key features of the 174 clinical studies on spinal neoplasms that were registered from 2000 to 2020. Clinical trials were heavily skewed toward the metastatic population as opposed to the primary tumors which likely reflects the rarity of the latter condition and associated challenges in undertaking prospective clinical studies in this population. This review serves to emphasize the need for a focused approach to enhancing translational research in spinal neoplasms with a particular emphasis on primary tumors.

Minimally invasive surgery for spinal cerebrospinal fluid-venous fistula ligation: patient series.

BACKGROUND: Cerebrospinal fluid-venous fistulas (CVFs) may cause cerebrospinal fluid leaks resulting in spontaneous intracranial hypotension (SIH). Surgical treatment of CVFs aims to eliminate abnormal fistulous connections between the subarachnoid space and the epidural venous plexus at the level of the nerve root sleeve. The authors propose a percutaneous minimally invasive technique for surgical ligation of CVF as an alternative to the traditional open approach using a tubular retractor system. OBSERVATIONS: Minimally invasive surgical (MIS) ligation of spinal CVF was performed in 5 patients for 6 CVFs. The definite disconnection of the CVF was achieved in all patients by clipping and additional silk tie ligation of the fistula. None of the patients experienced surgical complications or required transition to an open procedure. One patient underwent 2 MIS procedures for 2 separate CVFs. Postoperative clinical follow-up and cranial magnetic resonance imaging confirmed resolution of symptoms and radiographic SIH stigmata. LESSONS: MIS ligation of CVFs is safe and efficient. It represents an elegant and less invasive procedure, reducing the risk of wound infections and time to recovery. However, preparedness for open ligation is warranted within the same surgical setting in cases of complications and difficult accessibility.

Spinal arachnoid cysts: A case series & systematic review of the literature.

Introduction: Spinal arachnoid cysts (SACs) are rare lesions with challenging and controversial management. Research question: We analyzed our experiences from a case series and provide a systematic review to determine 1) Demographic and clinical features of SACs, 2) Optimal imaging for diagnosis and operative planning, 3) Optimal management of SACs, and 4) Clinical outcomes following surgery. Materials and methods: A single-institution, ambispective analysis of patients with symptomatic SACs surgically managed between May 2005 and May 2019 was performed. Data were collected as per local ethics committee stipulations. A systematic review of SACs in adults was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and a preapproved protocol. Results: Our series consisted of 11 patients, M:F 8:3, mean age 47.8 years (range 18-73 years). Mean follow-up was 19 months (range 5-36 months). SACs were excised or marsupialised (7), fenestrated (3) or partially excised (1). Eight patients had expansile duroplasty, 3 primary dural closure. One patient had a cystoperitoneal shunt. All patients were AIS D preoperatively; 4 remained unchanged and 7 improved to AIS E at follow-up. Our systematic search retrieved 725 citations. Fourteen case series met the inclusion criteria. There was no evidence to support superiority of one surgical strategy over another. Surgery for symptomatic patients resulted in positive clinical outcomes. Discussion and conclusions: Symptomatic SACs require surgical intervention. Limited evidence suggests that decompressing the cord, breakdown of arachnoid adhesions, and establishing CSF flow by consideration of expansile duroplasty are important for positive outcomes.

Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases.

INTRODUCTION AND IMPORTANCE: Long-level intramedullary astrocytomas complicated with spine scoliosis are rare. Surgical treatment of such tumors becomes more complicated and challenging when spinal scoliosis is present. However, studies describing the treatment of long segmental intramedullary spinal cord astrocytomas complicated with severe spine scoliosis have been rarely reported. CASE PRESENTATION: Two cases of long-level intramedullary astrocytomas complicated with severe spine scoliosis were surgically treated with one-stage operation of tumor resection and scoliosis correction in this report. Case 1: A 16-year-old boy presented to our hospital with a five-month progressive paresthesia, weakness of the left lower limb, and a long-time abnormal body appearance. MRI showed a T4-T12 intramedullary tumor combined with spinal scoliosis. Case 2: A 14-year-old boy presented at our service with a 6-year history of visible spine scoliosis and a 1-year progressive motor disability of bilateral lower limbs. Spine MRI indicated a long-level abnormal syringomyelia signal from C4 to L1 and there was irregular enhancement after intravenous contrast medium administration at C7-T2 and T9-T12 level. DISCUSSION: We performed a laminectomy over the whole length of the tumor and corrected the scoliosis with trans-pedicle screws. The patients exhibited a long-time tumor free with largely neurological function preservation. One-stage operation did not generate severe short- or long-term complications. The correction of the scoliosis prevented the progression of the spinal deformity and facilitated the recovery of normal life. CONCLUSION: This case report demonstrates that the one-stage resection of long-level intramedullary astrocytoma and correction of the complicated scoliosis might be a feasible option.

Utility of the spinal instability neoplastic score to identify patients with Gorham-Stout disease requiring spine surgery.

BACKGROUND: Gorham-Stout disease (GSD) is a rare syndrome presenting with progressive osteolysis which in the spine can lead to cord injury, instability, and deformity. Here, the early spine surgery may prevent catastrophic outcomes. CASE DESCRIPTION: A 25-year-old male with GSD involving the T2 to T6 levels presented with acute traumatic kyphoscoliosis at T3 and T4 and left lower extremity paraparesis. The CT scan 4 weeks before this showed progressing osteolysis versus the CT 5 years ago. Unfortunately, the patient underwent delayed treatment resulting in permanent neurological sequelae. Surgery included a laminectomy and vertebrectomy of T3/T4 with instrumented fusion from T1-10. The use of the spinal instability neoplastic score (SINS) is a useful tool to prompt early referral to spine surgeons. CONCLUSION: We recommend using the SINS score in GSD patients who develop spinal lesions to prompt early referral for consideration of surgery.

Clinical outcomes of nonoperatively managed degenerative cervical myelopathy: an ambispective longitudinal cohort study in 117 patients.

OBJECTIVE: Degenerative cervical myelopathy (DCM) is among the most common pathologies affecting the spinal cord but its natural history is poorly characterized. The purpose of this study was to investigate functional outcomes in patients with DCM who were managed nonoperatively as well as the utility of quantitative clinical measures and MRI to detect deterioration. METHODS: Patients with newly diagnosed DCM or recurrent myelopathic symptoms after previous surgery who were initially managed nonoperatively were included. Retrospective chart reviews were performed to analyze clinical outcomes and anatomical MRI scans for worsening compression or increased signal change. Quantitative neurological assessments were collected prospectively, including modified Japanese Orthopaedic Association (mJOA) score; Quick-DASH; graded redefined assessment of strength, sensation, and prehension-myelopathy version (GRASSP-M: motor, sensory, and dexterity); grip dynamometer; Berg balance scale score; gait stability ratio; and gait variability index. A deterioration of 10% was considered significant (e.g., a 2-point decrease in mJOA score). RESULTS: A total of 117 patients were included (95 newly diagnosed, 22 recurrent myelopathy), including 74 mild, 28 moderate, and 15 severe cases. Over a mean follow-up of 2.5 years, 57% (95% CI 46%-67%) of newly diagnosed patients and 73% (95% CI 50%-88%) of patients with recurrent DCM deteriorated neurologically. Deterioration was best detected with grip strength (60%), GRASSP dexterity (60%), and gait stability ratio (50%), whereas the mJOA score had low sensitivity (33%) in 50 patients. A composite score had a sensitivity of 81% and a specificity of 82%. The sensitivity of anatomical MRI was 28% (83 patients). CONCLUSIONS: DCM appears to have a poor natural history; however, prospective studies are needed for validation. Serial assessments should include mJOA score, grip strength, dexterity, balance, and gait analysis. The absence of worsening on anatomical MRI or in mJOA scores is not sufficient to determine clinical stability.

Inter-rater Reliability of the Modified Japanese Orthopedic Association Score in Degenerative Cervical Myelopathy: A Cross-sectional Study.

STUDY DESIGN: Prospective cross-sectional blinded-assessor cohort study. OBJECTIVE: The aim of this study was to determine the inter-rater reliability of the modified Japanese Orthopaedic Association (mJOA) score in a large cohort of degenerative cervical myelopathy (DCM) patients. SUMMARY OF BACKGROUND DATA: The mJOA score is widely accepted as the primary outcome measure in DCM; it has been utilized in clinical practice guidelines and directly influences treatment recommendations, but its reliability has not been established. METHODS: A refined version of the mJOA was administered to DCM patients by two or more blinded clinicians. Inter-rater reliability was measured using intraclass correlation coefficient (ICC), agreement, and mean difference for mJOA total score and subscores. Data were also analyzed with analysis of variance for differences by mJOA severity (mild: 15-17, moderate: 12-14, severe: <12), assessor, assessment order, previous surgery, age, and sex. RESULTS: One hundred fifty-four DCM patients underwent 322 mJOA assessments (183 paired assessments). ICC was 0.88 for total mJOA, 0.79 for upper extremity (UE) motor, 0.84 for lower extremity (LE) motor, 0.63 for UE sensation, and 0.78 for urinary function subscores. Paired assessments were identical across all four subscores in 25%. The mean difference in mJOA was 0.93 points between assessors, and this differed by severity (mild: 0.68, moderate: 1.24, severe: 0.87, P = 0.001). Differences of ≥ 2 points occurred in 19%. Disagreement between mild and moderate severity occurred in 12% of patients. Other variables did not demonstrate significant relationships with mJOA scores. CONCLUSION: The inter-rater reliability of total mJOA and its subscores is good, except for UE sensory function (moderate). However, the vast majority of assessments differed between observers, indicating that this measure should be interpreted carefully, particularly when near the threshold between severity categories, or when a patient is reassessed for deterioration. Further efforts to educate clinicians on administration and to refine the UE sensory subscore may enhance the reliability of this tool.Level of Evidence: 1.