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PURPOSE: To develop and validate a noninvasive imaging technique for accurately assessing very slow CSF flow within shunt tubes in pediatric patients with hydrocephalus, aiming to identify obstructions that might impede CSF drainage. THEORY AND METHODS: A simulation of shunt flow enhancement of signal intensity (shunt-FENSI) signal is used to establish the relationship between signal change and flow rate. The quantification of flow enhancement of signal intensity data involves normalization, curve fitting, and calibration to match simulated data. Additionally, a phase sweep method is introduced to accommodate the impact of magnetic field inhomogeneity on the flow measurement. The method is tested in flow phantoms, healthy adults, intensive care unit patients with external ventricular drains (EVD), and shunt patients. EVDs enable shunt-flow measurements to be acquired with a ground truth measure of CSF drainage. RESULTS: The flow-rate-to-signal simulation establishes signal-flow relationships and takes into account the T1 of draining fluid. The phase sweep method accurately accounts for phase accumulation due to frequency offsets at the shunt. Results in phantom and healthy human participants reveal reliable quantification of flow rates using controlled flows and agreement with the flow simulation. EVD patients display reliable measures of flow rates. Shunt patient results demonstrate feasibility of the method and consistent flow rates for functional shunts. CONCLUSION: The results demonstrate the technique's applicability, accuracy, and potential for diagnosing and noninvasively monitoring hydrocephalus. Limitations of the current approach include a high sensitivity to motion and strict requirement of imaging slice prescription.
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Derivaciones del Líquido Cefalorraquídeo , Hidrocefalia , Imagen por Resonancia Magnética , Fantasmas de Imagen , Humanos , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/fisiopatología , Imagen por Resonancia Magnética/métodos , Adulto , Masculino , Femenino , Reproducibilidad de los Resultados , Simulación por Computador , Niño , Líquido Cefalorraquídeo/diagnóstico por imagen , Líquido Cefalorraquídeo/fisiología , Algoritmos , Procesamiento de Imagen Asistido por Computador/métodosRESUMEN
Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.
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Bloqueo Nervioso , Dolor Postoperatorio , Humanos , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Bloqueo Nervioso/métodos , Anestésicos Locales/administración & dosificación , Ensayos Clínicos Controlados Aleatorios como Asunto , Músculos Paraespinales , Columna Vertebral/cirugía , Manejo del Dolor/métodosRESUMEN
OBJECTIVE: In the United States, more than 1 million sport-related concussions afflict children annually, with many cases undetected or unreported. The Sport Concussion Assessment Tool (SCAT) is widely used to detect concussions in high school, collegiate, and professional sports. The objective of this study was to establish baseline values for the SCAT version 5 (SCAT5) in high school athletes. METHODS: Baseline SCAT5 evaluations were conducted in students (ages 14-19 years) from 19 high schools in central Illinois who were participating in various school-sponsored sports. The SCAT5 evaluations were retrospectively extracted from the electronic medical record system for analysis. Statistical analyses included the Wilcoxon rank-sum test for continuous variables and the chi-square test for categorical variables, considering significance at p < 0.05. Test-retest reliability at < 6 months, 10-14 months, and 16-20 months was computed using intraclass correlation and Spearman's rho (ρ). Reliable change indices are provided using the Iverson formula. RESULTS: A total of 2833 unique athletes were included, and the average age was 15.5 ± 1.14 (SD) years. There were 721 female (25.5%) and 2112 male (74.5%) athletes. Students ≥ 15 years old had more prior concussions (p < 0.001), and male athletes were more frequently hospitalized for head injury (p = 0.013). Female athletes exhibited a significantly higher prevalence of mood disorders (14.7% vs 4.6%, p < 0.001), whereas attention-deficit/hyperactivity disorder was more common in male athletes (5.2% vs 13.2%, p < 0.001). Symptom number and severity were significantly greater in female athletes (3.17 ± 4.39 vs 2.08 ± 3.49, p < 0.001; 5.47 ± 9.21 vs 3.52 ± 7.26, p < 0.001, respectively), with mood-related symptoms representing the largest differences. Female athletes and students ≥ 15 years old performed better on most cognitive assessments. Female athletes and students < 15 years old performed better on the modified Balance Error Scoring System (p < 0.001). Test-retest reliability was poor to moderate for most assessment components. Reliable change index cutoff values differed slightly by sex, with female athletes often having a greater cutoff value. CONCLUSIONS: This study underscores the variability of SCAT5 baseline values influenced by age, sex, and medical history among adolescent athletes. It provides a robust dataset, delineating baseline values stratified by sex and age within this demographic. Additionally, the results provide enhanced guidance to clinicians for interpretation of change and reliability of baselines.
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Atletas , Traumatismos en Atletas , Conmoción Encefálica , Humanos , Adolescente , Masculino , Femenino , Conmoción Encefálica/diagnóstico , Conmoción Encefálica/epidemiología , Reproducibilidad de los Resultados , Adulto Joven , Traumatismos en Atletas/diagnóstico , Estudios Retrospectivos , Pruebas Neuropsicológicas/normas , Instituciones Académicas , Estudiantes/estadística & datos numéricosRESUMEN
BACKGROUND: Spinal metastases are commonly seen in patients with cancer and often indicate a poor prognosis. Treatment can include curative or palliative surgery, chemotherapy, and radiation therapy. The surgical approach varies widely on the basis of the affected region of the spine, the location of the tumor (anterior versus posterior), the goal of surgery, the health of the patient, and surgeon preference. OBSERVATIONS: The authors present a case of a 68-year-old male with intractable lower-back pain and substantially diminished ambulation. Diagnostic imaging revealed a lumbar metastasis from a cholangiocarcinoma primary at L2-3 (4.5 cm anteroposterior × 5.7 cm transverse × 7.0 cm craniocaudal). The patient underwent a 2-level vertebrectomy with expandable cage placement and T10 to S2 fusion via a posterior-only approach. The patient regained much of his mobility and quality of life after the surgery. LESSONS: Although this was a high-risk surgery, the authors show that a posterior-only approach can be used for lumbar vertebrectomies and fusion when necessary. Palliative surgeries carrying a high risk, especially in the setting of a limited prognosis, should include multidisciplinary deliberations and a thorough discussion of the risks and outcome expectations with the patient.
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Background: Facet arthroplasty, an alternative to lumbar fusion, offers stabilization and preserves range of motion. This subanalysis of the TOPS IDE trial (FDA #G160168) compared facet arthroplasty, using the TOPS device, with a standard single-level transforaminal lumbar interbody fusion (TLIF) in patients stratified by age (<65 and ≥65 years) with symptomatic grade 1 degenerative spondylolisthesis with moderate to severe spinal stenosis at L2-5. Methods: Patient-reported outcomes (PROMS), including Oswestry disability index (ODI), visual analog pain scales (VAS), and Zurich claudication questionnaires (ZCQ), were assessed at baseline and multiple postoperative timepoints. Radiographic evaluation of flexion/extension range of motion (ROM) occurred at baseline, 12 months, and 24 months. Data were analyzed following an intention-to-treat model. Significance was defined as p<.05. Results: About 299 patients were included (TOPS=206, TLIF=93). The groups were similar at baseline. At 2 years, the TOPS group had a greater proportion of patients report ≥15-point improvement for ODI (93.8% versus 77.1%, p=.011) and ≥20-point improvement for VAS back (84.4% versus 61.8%, p=.014). At 1 year, TOPS group had a greater proportion of patients report clinically significant improvements in all ZCQ categories (91.6% versus 78.5%, p=.012). In patients <65 years, the TOPS group had improved PROMS compared to TLIF at 2 years; however, these differences were less pronounced in patients ≥65 years old. The TOPS groups preserved more ROM at 12 (2.8° 95%CI [1.87; 3.74], p<.0001) and 24 (2.99° 95%CI [1.82; 4.15], p<.0001) months compared to TLIF. ROM was similarly preserved in patients aged <65 and ≥65. The rate of adverse events did not differ significantly between treatment groups. Conclusions: Facet arthroplasty preserves more ROM in all ages and leads to improved PROMS compared to TLIF, particularly in younger patients.
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STUDY DESIGN: Retrospective study with epidemiologic analysis of public Medicare data. OBJECTIVE: The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations. SUMMARY OF BACKGROUND DATA: Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level. METHODS: Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care. RESULTS: A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( ß =-0.13, 95% CI: -0.16, -0.10). CONCLUSIONS: Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care. LEVEL OF EVIDENCE: Level III-retrospective.
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Vértebras Cervicales , Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud , Fusión Vertebral , Humanos , Estados Unidos , Vértebras Cervicales/cirugía , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Femenino , Masculino , Factores Socioeconómicos , Medicare , Anciano , Población Urbana/estadística & datos numéricosRESUMEN
Introduction: Severe pain, anxiety, and high opioid use are common following lumbar spine surgery (LSS). Yoga helps to reduce pain and anxiety, but it has not been considered for postsurgical care. The authors developed and tested the feasibility of a tailored yoga program designed for individuals undergoing LSS and explored clinical feasibility of yoga intervention on measures of pain, function, psychological status, and opioid use. Methods: Individuals scheduled for LSS were randomized into yoga versus control groups presurgery. Participants in the yoga group received tailored yoga sessions plus usual care, whereas participants in the control group received usual care only during the hospital stay post-LSS. In-person daily yoga sessions were individually presented and performed in the participant's hospital room. Feasibility was assessed by recruitment and retention rates, rate of yoga session completion, tolerance to yoga intervention, and ability to carry out planned assessment. Exploratory clinical outcomes included pain, psychological measures, Timed-Up-and-Go test, gait distance, and opioid use, during the hospital stay post-LSS. Results: Forty-one participants were enrolled, of which 30 completed. There were no dropouts. Planned assessments were completed within 45 min, suggesting no excessive burden on participants. Baseline variables were similar across both groups. The majority of participants participated in yoga intervention on the day of surgery or one day after surgery with acceptance rate of 100%. Participants showed good tolerance to yoga intervention on 0-4 tolerance scale and by their reports of exploratory clinical outcomes. Conclusion: This study indicates feasibility for a modified yoga program for postoperative care following LSS due to participant tolerance and retention. The results provide preliminary framework for future confirmatory studies that can assess the potential benefits of yoga in reducing pain, catastrophizing behavior, and opioid use and improving function. A modified yoga program focusing on diaphragmatic breathing, relaxation, and core isometric contraction exercises can be an important adjunct intervention for patients undergoing LSS. CTR Number: This trial was registered in UMIN CTR (https://rctportal.niph.go.jp/en/) with registration number: UMIN000032595.
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OBJECTIVE: Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to be effective for pain modulation in a variety of pathological conditions causing neuropathic pain. The purpose of this study is to conduct a network meta-analysis (NMA) of randomized control trials to identify the most optimal frequency required to achieve chronic pain modulation using rTMS. METHODS: A comprehensive search was conducted in electronic databases to identify randomized controlled trials investigating the efficacy of rTMS for chronic pain management. A total of 24 studies met the inclusion criteria, and a NMA was conducted to identify the most effective rTMS frequency for chronic pain management. RESULTS: Our analysis revealed that high frequency rTMS (20 Hz) was the most effective frequency for chronic pain modulation. Patients treated with 20 Hz had lower pain levels than those treated at 5 Hz (mean difference [MD] = -3.11 [95% confidence interval {CI}: -5.61 - -0.61], P = 0.032) and control (MD = -1.99 [95% CI: -3.11 - -0.88], P = 0.023). Similarly, treatment with 10 Hz had lower pain levels compared to 5 Hz (MD = -2.56 [95% CI: -5.05 - -0.07], P = 0.045) and control (MD = -1.44 [95% CI: -2.52 - -0.36], P = 0.031). 20 Hz and 10 Hz were not statistically different. CONCLUSIONS: This NMA suggests that high frequency rTMS (20 Hz) is the most optimal frequency for chronic pain modulation. These findings have important clinical implications and can guide healthcare professionals in selecting the most effective frequency for rTMS treatment in patients with chronic pain.
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Dolor Crónico , Manejo del Dolor , Estimulación Magnética Transcraneal , Humanos , Dolor Crónico/terapia , Metaanálisis en Red , Neuralgia/terapia , Manejo del Dolor/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Estimulación Magnética Transcraneal/métodos , Resultado del TratamientoRESUMEN
STUDY DESIGN: This study is a mixed methods approach. OBJECTIVES: Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. METHODS: Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. RESULTS: An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. CONCLUSIONS: This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.
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STUDY DESIGN: Scoping Review. OBJECTIVE: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.
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BACKGROUND AND OBJECTIVES: Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW. METHODS: In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS: A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively. CONCLUSION: Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.
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BACKGROUND AND OBJECTIVES: The palliative impact of spine surgery for metastatic disease is evolving with improvements in surgical technique and multidisciplinary cancer care. The goal of this study was to prospectively evaluate long-term clinical outcomes including health-related quality-of-life (HRQOL) measures, using spine cancer-specific patient-reported-outcome (PRO) measures, in patients with symptomatic spinal metastases who underwent surgical management. METHODS: The Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO, ClinicalTrials.gov identifier: NCT01825161) trial is a prospective-observational cohort study that included 10 specialist centers in North America and Europe. Patients aged 18 to 75 years who underwent surgery for spinal metastases were included. Prospective assessments included both spine tumor-specific and generic PRO tools which were collected for a minimum of 2 years post-treatment or until death. RESULTS: Two hundred and eighty patients (51.8% female, mean age 57.9 years) were included. At presentation, the mean Charlson Comorbidity Index was 6.0, 35.7% had neurological deficits as defined by the American Spinal Cord Injury Association scores, 47.2% had high-grade epidural spinal cord compression (2-3), and 89.6% had impending or frank instability as measured by a Spinal Instability Neoplastic Score of ≥7. The most common primary tumor sites were breast (20.2%), lung (18.8%), kidney (16.2%), and prostate (6.5%). The median overall survival postsurgery was 501 days, and the 2-year progression-free-survival rate was 38.4%. Compared with baseline, significant and durable improvements in HRQOL were observed at the 6-week, 12-week, 26-week, 1-year, and 2-year follow-up assessments from a battery of PRO questionnaires including the spine cancer-specific, validated, Spine Oncology Study Group Outcomes Questionnaire v2.0, the Short Form 36 version 2, EuroQol-5 Dimension (3L), and pain numerical rating scale score. CONCLUSION: Multi-institutional, prospective-outcomes data confirm that surgical decompression and/or stabilization provides meaningful and durable improvements in multiple HRQOL domains, including spine-specific outcomes based on the Spine Oncology Study Group Outcomes Questionnaire v2.0, for patients with metastatic spine disease.
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STUDY DESIGN: Clinical practice guideline development following the GRADE process. OBJECTIVES: Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. METHODS: A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. RESULTS: The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the "lower limit," but not actively augmented beyond an "upper limit" of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the "target MAP" was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG "suggested" that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. CONCLUSION: We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.
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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.
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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.
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Vértebras Cervicales , Riluzol , Humanos , Riluzol/uso terapéutico , Masculino , Femenino , Persona de Mediana Edad , Método Doble Ciego , Vértebras Cervicales/cirugía , Anciano , Enfermedades de la Médula Espinal/cirugía , Enfermedades de la Médula Espinal/tratamiento farmacológico , Espondilosis/cirugía , Espondilosis/tratamiento farmacológico , Resultado del Tratamiento , Fármacos Neuroprotectores/uso terapéuticoRESUMEN
STUDY DESIGN: Clinical practice guideline development. OBJECTIVES: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.
RESUMEN
STUDY DESIGN: Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE: The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS: All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS: Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION: We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.
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STUDY DESIGN: Retrospective review of prospective, multicenter and international cohort study. OBJECTIVE: To describe the effect of gender on HRQoL, clinical outcomes and survival for patients with spinal metastases treated with either surgery and/or radiation. SUMMARY OF BACKGROUND DATA: Gender differences in health-related outcomes are demonstrated in numerous studies, with women experiencing worse outcomes and receiving lower standards of care than men, however, the influence that gender has on low health-related quality of life (HRQoL) and clinical outcomes after spine surgery remains unclear. METHODS: Patient demographic data, overall survival, treatment details, perioperative complications, and HRQoL measures including EQ-5D, pain NRS, the short form 36 version 2 (SF-36v2) and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) were reviewed. Patients were stratified by sex, and a separate sensitivity analysis that excluded gender-specific cancers (i.e., breast, prostate, etc.) was performed. RESULTS: The study cohort included 207 female and 183 male patients, with age, smoking status, and site of primary cancer being significantly different between the two cohorts (P<0.001). Both males and females experienced significantly improved SOSGOQ2.0, EQ-5D, and pain NRS scores at all study time points from baseline (P<0.001). Upon sensitivity analysis, (gender-specific cancers removed from analysis), the significant improvement in SOSGOQ physical, mental, and social subdomains and on SF-36 domains disappeared for females. Males experienced higher rates of postoperative complications. Kaplan-Meier survival analysis of both the overall and sensitivity analysis cohorts showed females lived longer than males after treatment (P=0.001 and 0.043, respectively). CONCLUSION: Both males and females experienced significantly improved HRQoL scores after treatment, but females demonstrated longer survival and a lower complication rate. This study suggests that gender may be a prognostic factor in survival and clinical outcomes for patients undergoing treatment for spine metastases and should be taken into consideration when counseling patients accordingly.
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To report on a case of pheochromocytoma metastases to the spine occurring more than 20 years after initial diagnosis. A 34-year-old female with a history of metastatic pheochromocytoma diagnosed at age 12 presented with weakness, heart palpitations, and circumferential back pain of five months duration. The patient had undergone multiple laparatomies for abdominal and hepatic metastases. Work-up revealed a destructive lesion at T9. After two weeks of preoperative phenoxybenzamine to control her hypertension, she underwent decompression, posterior fixation and fusion. Surgical intervention was followed by radiation therapy, zoledronic acid, and only one cycle of chemotherapy due to intolerance of side effects. The patient survived 25 years after original diagnosis, which far exceeds the average survival of less than 15 years. The patient died 26 months postoperatively due to progression of disease. Pheochromocytoma with spine metastases occurring more than 20 years after diagnosis is very uncommon, and should be considered in the differential diagnosis of a patient with a history of pheochromocytoma.
Relato de caso de feocromocitoma adrenal com metástase para a coluna que ocorreu há mais de 20 anos após o diagnóstico inicial. Mulher de 34 anos com história de feocromocitoma metastático diagnosticado na idade de 12 anos, apresentando fraqueza, palpitações do coração e dor nas costas circunferencial há cinco meses. A paciente tinha realizado laparotomia para metástases abdominal e hepática. Durante o procedimento revelou uma lesão destrutiva em T9. Após duas semanas de fenoxibenzamina pré-operatórios para controlar sua hipertensão, submeteu-se a descompressão, fixação e posterior fusão. A intervenção cirúrgica foi seguida por terapia de radiação, ácido zoledrônico e apenas um ciclo de quimioterapia, devido à intolerância e aos efeitos colaterais. A paciente sobreviveu 25 anos após o diagnóstico original, o que excede em muito a sobrevida média de menos de 15 anos. A paciente morreu 26 meses após o pós-operatório, devido à progressão da doença. Feocromocitoma com metástases para coluna ocorrida há mais de 20 anos após o diagnóstico é muito raro, devendo ser considerada no diagnóstico diferencial de um paciente com uma história de feocromocitoma.
Relato de un caso de feocromocitoma adrenal con metástasis para la columna que ocurrió con más de 20 años de diagnóstico inicial. Mujer de 34 años con historia de feocromocitoma metastásico diagnosticado en la edad de 12 años, con presencia de debilidad, palpitaciones del corazón y dolor en la espalda circunferencial, con evolución de cinco meses. A la paciente se le había realizado diversas laparotomías por causa de metástasis abdominales y hepáticas. Durante la inspección, se mostró una lesión destructiva en T9. Después de dos semanas de fenoxibenzamina preoperatoria para controlar la hipertensión, se sometió a descompresión, fijación y posterior fusión. La intervención quirúrgica fue seguida por radioterapia, ácido zoledrónico, y sólo un ciclo de quimioterapia, debido a la intolerancia y a los efectos colaterales.La paciente sobrevivió 25 años después del diagnóstico original, lo que excedió en mucho la sobrevida mediana de menos de 15 años. La paciente murió 26 meses después del postoperatorio debido a la progresión de la enfermedad. El hecho de la metástasis para columna haber ocurrido después de 20 años del diagnóstico es bastante raro y se debe considerar en el diagnóstico diferencial de un paciente con una historia de feocromocitoma.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Diagnóstico Diferencial , Metástasis de la Neoplasia , Paraganglioma , Feocromocitoma , Compresión de la Médula Espinal , Sobrevida , Vértebras TorácicasRESUMEN
Pigmented Villonodular Synovitis (PVNS), a lesion of the synovial tissues, is rarely found in the spine. We present a 73-year-old male with increasing lower extremity weakness and paresthesias. MRI scans revealed disc herniation and spinal cord compression at the T11-T12 and T12- L1 levels. Intraoperative exploration revealed an epidural mass originating in the T12 lamina, compressing the spinal cord at T11-T12. Pathologic examination was consistent with pigmented villonodular synovitis.
Sinovitis pigmentada vilonodular (PVNS) é uma lesão do tecido sinovial e raramente é encontrada na coluna vertebral. Apresentamos o caso de um homem de 73 anos de idade com aumento de fraqueza da extremidade inferior e parestesia. O exame de imagem por ressonância magnética revelou hérnia de disco e compressão no nível T11-T12 e T12-L1. A exploração cirúrgica evidenciou massa epidural orginária em T2 e compressão da medula espinhal no nível de T11-T12. O exame patológico foi compatível com sinovitis pigmentada vilonodular .
Sinovitis vellonodular pigmentada (PVNS) es una lesión del tejido sinovial y raramente se encuentra en la columna vertebral. Presentamos el caso de un hombre de 73 años de edad que mostró aumento de la flaqueza de la extremidad inferior y parestesias. El examen de imagen por resonancia magnética indicó una hernia de disco y compresión en el nivel de T11-T12 y T12-L1. La exploración quirúrgica evidenció una masa epidural originaria en T2 y compresión de la médula espinal a nivel de T11-T12. El examen patológico fue compatible con sinovitis vellonodular pigmentada.