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Spinal meningiomas are relatively rare, but account for a significant proportion of primary spinal tumors in adults. These meningiomas can be found anywhere along the spinal column and their diagnosis is often delayed due to their slow growth and the lack of significant neurological symptoms until they reach a critical size, at which point signs of spinal cord or nerve root compression generally manifest and progress. If left untreated, spinal meningiomas can cause severe neurological deficits including rendering patients paraplegic or tetraplegic. In this chapter we will review the clinical features of spinal meningiomas, their surgical management, and detail molecular features that differentiate them from intracranial meningiomas.
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Neoplasias Meníngeas , Meningioma , Neoplasias de la Médula Espinal , Adulto , Humanos , Neoplasias de la Médula Espinal/diagnóstico , Columna VertebralRESUMEN
BACKGROUND: This study was designed to identify preoperative predictors of survival in surgically treated patients with metastatic epidural spinal cord compression (MESCC), to examine how these predictors are related to 8 prognostic models, and to perform the first full external validation of these models in accordance with the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement. METHODS: One hundred forty-two surgically treated patients with MESCC were enrolled in a prospective, multicenter North American cohort study and were followed for 12 months or until death. Cox regression was used. Noncollinear predictors with < 10% missing data, with ≥ 10 events per stratum, and with P < .05 in a univariate analysis were tested through a backward stepwise selection. For the original and revised Tokuhashi prognostic scoring systems (PSSs), Tomita PSS, modified Bauer PSS, van der Linden PSS, Bartels model, Oswestry Spinal Risk Index, and Bollen PSS, this study examined calibration graphically, discrimination with Harrell c-statistics, and survival stratified by risk groups with the Kaplan-Meier method and log-rank test. RESULTS: The following were significant in the univariate analysis: type of primary tumor, sex, organ metastasis, body mass index, preoperative radiotherapy to MESCC, physical component (PC) of the 36-Item Short Form Health Survey, version 2 (SF-36v2), and EuroQol 5-Dimension (EQ-5D) Questionnaire. Breast, prostate and thyroid primary tumor (HR: 2.9; P =.0005), presence of organ metastasis (hazard ratio (HR): 2.0; P = .005) and SF-36v2 PC (HR: 0.95; P < .0001) were associated with survival in multivariable analysis. Predicted prognoses poorly matched observed values on calibration plots; Bartels model calibration slope was 0.45. Bollen PSS (0.61; 95% CI: 0.58-0.64) and Bartels model (0.68; 95% CI: 0.65-0.71) had the lowest and highest c-statistics, respectively. CONCLUSIONS: The primary tumor type (breast, prostate, or thyroid), an absence of organ metastasis, and a lower degree of physical disability are preoperative predictors of longer survival for surgical MESCC patients. These results are in keeping with current models. This full external validation of 8 prognostic PSSs or model of survival in surgical MESCC patients has revealed that calibration is poor, especially for long-term survivors, whereas discrimination is possibly helpful.
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Neoplasias Epidurales/mortalidad , Neoplasias Epidurales/cirugía , Modelos Estadísticos , Compresión de la Médula Espinal/mortalidad , Compresión de la Médula Espinal/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Descompresión Quirúrgica/mortalidad , Descompresión Quirúrgica/estadística & datos numéricos , Neoplasias Epidurales/complicaciones , Neoplasias Epidurales/secundario , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , América del Norte/epidemiología , Valor Predictivo de las Pruebas , Pronóstico , Compresión de la Médula Espinal/diagnóstico , Compresión de la Médula Espinal/etiología , Neoplasias de la Columna Vertebral/complicaciones , Neoplasias de la Columna Vertebral/mortalidad , Neoplasias de la Columna Vertebral/secundario , Neoplasias de la Columna Vertebral/cirugía , Análisis de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
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.
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Neoplasias de la Médula Espinal/patología , Neoplasias de la Médula Espinal/cirugía , Adolescente , Adulto , Anciano , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/patología , Vértebras Cervicales/cirugía , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Médula Espinal/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagen , Vértebras Torácicas/patología , Vértebras Torácicas/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
STUDY DESIGN: Systematic review. Surgical decompression for degenerative cervical myelopathy (DCM) is associated with perioperative complications, including difficulty or discomfort with swallowing (dysphagia) as well as changes in sound production (dysphonia). This systematic review aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system. METHODS: An electronic database search was conducted for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery. Data extracted included study design, surgical details, as well as definitions and rates of surgical complications. A 4-point rating scale was developed to assess the quality of definitions for each complication. RESULTS: Our search yielded 2,673 unique citations, 11 of which met eligibility criteria and were summarized in this review. Defined complications included odynophagia (n = 1), dysphagia (n = 11), dysphonia (n = 2), perioperative swelling complications (n = 2), and soft tissue swelling (n = 3). Rates of dysphagia varied substantially (0.0%-50.0%) depending on whether this complication was patient-reported (4.4%); patient-reported using a modified Swallowing Quality of Life questionnaire (43.1%) or the Bazaz criteria (8.8%-50.0%); or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia also ranged significantly from 0.6% to 38.0%. CONCLUSION: There is substantial variability in reported rates of dysphagia and dysphonia due to differences in data collection methods, diagnostic strategies, and definitions. Consolidation of nomenclature will improve evaluation of the overall safety of surgery.
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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, Pâ=â0.001). Differences of ≥â2 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.
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Ortopedia , Enfermedades de la Médula Espinal , Vértebras Cervicales/cirugía , Estudios de Cohortes , Estudios Transversales , Humanos , Japón/epidemiología , Estudios Prospectivos , Reproducibilidad de los Resultados , Enfermedades de la Médula Espinal/diagnóstico , Enfermedades de la Médula Espinal/cirugíaRESUMEN
Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.
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Manejo de la Enfermedad , Cuidados Posoperatorios/métodos , Medicina de Precisión/métodos , Calidad de Vida , Compresión de la Médula Espinal/cirugía , Neoplasias de la Columna Vertebral/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Bases de Datos Factuales/tendencias , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/tendencias , Medicina de Precisión/tendencias , Pronóstico , Estudios Prospectivos , Calidad de Vida/psicología , Compresión de la Médula Espinal/mortalidad , Compresión de la Médula Espinal/psicología , Neoplasias de la Columna Vertebral/mortalidad , Neoplasias de la Columna Vertebral/psicología , Tasa de Supervivencia/tendencias , Adulto JovenRESUMEN
STUDY DESIGN: Review. OBJECTIVES: The objectives of this review are to (a) summarize the role of clinical practice guidelines (CPGs), (b) outline the methodology involved in formulating CPGs, (c) provide an illustration of these principles using a CPG developed for degenerative cervical myelopathy, and (d) highlight the importance of knowledge translation. METHODS: A review of the literature was conducted to summarize current standards in CPG development and implementation. RESULTS: CPGs are systematically developed statements intended to affect decisions made by health care providers, policy makers, and patients. The main objectives of CPGs are to synthesize and translate evidence into recommendations, optimize patient outcomes, standardize care, and facilitate shared decision making among physicians, patients, and their caregivers. The main steps involved in the development of CPGs include defining the clinical problem, assembling a multidisciplinary guideline development group and systematic review team, conducting a systematic review of the literature, translating the evidence to recommendations, critically appraising the CPG and updating the document when new studies arise. The final step in developing a CPG is to implement it into clinical practice; this step requires an assessment of the barriers to implementation and the formulation of effective dissemination strategies. CONCLUSION: CPGs are an important component in the teaching and practice of medicine and are available for a wide spectrum of diseases. CPGs, however, can only be used to influence clinical practice if the recommendations are informed by a systematic review of the literature and developed using rigorous methodology. The opportunity to transform clinical management of spinal conditions is an attractive outcome of the application of high-quality CPGs.
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Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.
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Manejo de la Enfermedad , Neoplasias de la Columna Vertebral/terapia , Humanos , Dolor/etiología , Parálisis/etiología , Radiocirugia , Compresión de la Médula Espinal/etiología , Neoplasias de la Columna Vertebral/complicacionesRESUMEN
BACKGROUND: Congenital spinal stenosis (CSS) of the cervical spine is a risk factor for acute spinal cord injury and development of degenerative cervical myelopathy (DCM). OBJECTIVE: To develop magnetic resonance imaging (MRI)-based criteria to diagnose preexisting CSS and evaluate differences between patients with and without CSS. METHODS: A secondary analysis of international prospectively collected data between 2005 and 2011 was conducted. We examined the data of 349 surgical DCM patients and 27 controls. Spinal canal and cord anteroposterior diameters were measured at noncompressed sites to calculate spinal cord occupation ratio (SCOR). Torg-Pavlov ratios and spinal canal diameters from radiographs were correlated with SCOR. Clinical and MRI factors were compared between patients with and without CSS. Surgical outcomes were also assessed. RESULTS: Calculation of SCOR was feasible in 311/349 patients. Twenty-six patients with CSS were identified (8.4%). Patients with CSS were younger than patients without CSS (P = .03) and had worse baseline severity as measured by the modified Japanese Orthopedic Association score (P = .04), Nurick scale (P = .05), and Neck Disability Index (P < .01). CSS patients more commonly had T2 cord hyperintensity changes (P = .09, ns) and worse SF-36 Physical Component scores (P = .06, ns). SCOR correlated better with Torg-Pavlov ratio and spinal canal diameter at C3 than C5. Patients with SCOR ≥ 65% were also younger but did not differ in baseline severity. CONCLUSION: SCOR ≥ 70% is an effective criterion to diagnose CSS. CSS patients develop myelopathy at a younger age and have greater impairment and disability than other patients with DCM. Despite this, CSS patients have comparable duration of symptoms, MRI presentations, and surgical outcomes to DCM patients without CSS.
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Vértebras Cervicales/diagnóstico por imagen , Internacionalidad , Imagen por Resonancia Magnética/métodos , Informe de Investigación , Enfermedades de la Médula Espinal/diagnóstico por imagen , Estenosis Espinal/diagnóstico por imagen , Adulto , Anciano , Vértebras Cervicales/cirugía , Estudios de Cohortes , Femenino , Salud Global , Humanos , Imagen por Resonancia Magnética/normas , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Enfermedades de la Médula Espinal/cirugía , Estenosis Espinal/cirugíaRESUMEN
Commentary On: Hicks K.E., Zhao Y., Fallah N, Rivers C, Noonan V, Plashkes T, Wai EK, Roffey DM, Tsai E, Paquet J, Attabib N, Marion T, Ahn H, Phan P. A simplified clinical prediction rule for prognosticating independent walking after spinal cord injury: a prospective study from a Canadian multicenter spinal cord injury registry. The Spine Journal. Article in press.
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Traumatismos de la Médula Espinal , Caminata , Canadá , Técnicas de Apoyo para la Decisión , Humanos , Estudios Prospectivos , Sistema de RegistrosRESUMEN
PURPOSE: While several clinical prediction rules (CPRs) of survival exist for patients with symptomatic spinal metastasis (SSM), these have variable prognostic ability and there is no recognized CPR for health related quality of life (HRQoL). We undertook a critical appraisal of the literature to identify key preoperative prognostic factors of clinical outcomes in patients with SSM who were treated surgically. The results of this study could be used to modify existing or develop new CPRs. METHODS: Seven electronic databases were searched (1990-2015), without language restriction, to identify studies that performed multivariate analysis of preoperative predictors of survival, neurological, functional and HRQoL outcomes in surgical patients with SSM. Individual studies were assessed for class of evidence. The strength of the overall body of evidence was evaluated using GRADE for each predictor. RESULTS: Among 4,818 unique citations, 17 were included; all were in English, rated Class III and focused on survival, revealing a total of 46 predictors. The strength of the overall body of evidence was very low for 39 and low for 7 predictors. Due to considerable heterogeneity in patient samples and prognostic factors investigated as well as several methodological issues, our results had a moderately high risk of bias and were difficult to interpret. CONCLUSIONS: The quality of evidence for predictors of survival was, at best, low. We failed to identify studies that evaluated preoperative prognostic factors for neurological, functional, or HRQoL outcomes in surgical patients with SSM. We formulated methodological recommendations for prognostic studies to promote acquiring high-quality evidence to better estimate predictor effect sizes to improve patient education, surgical decision-making and development of CPRs.
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Calidad de Vida , Neoplasias de la Columna Vertebral/secundario , Bases de Datos Factuales , Toma de Decisiones , Técnicas de Apoyo para la Decisión , Humanos , Pronóstico , Neoplasias de la Columna Vertebral/mortalidad , Neoplasias de la Columna Vertebral/cirugíaRESUMEN
OBJECTIVES: There is no standardized approach to assess and manage perioperative neurologic deficit (PND) in patients undergoing spinal surgery. This survey aimed to evaluate the awareness and usage of clinical practice guidelines (CPGs) as well as investigate how surgeons performing spine surgeries feel about and manage PND and how they perceive the value of developing CPGs for the management of PND. METHODS: An invitation to participate was sent to the AOSpine International community. Questions were related to the awareness, usage of CPGs, and demographics. Results from the entire sample and subgroups were analyzed. RESULTS: Of 770 respondents, 659 (85.6%) reported being aware of the existence of guideline(s), and among those, 578 (87.7%) acknowledged using guideline(s). Overall, 58.8% of surgeons reported not feeling comfortable managing a patient who wakes up quadriplegic after an uneventful multilevel posterior cervical decompression with instrumented fusion. Although 22.9% would consider an immediate return to the operating room, the other 77.1% favored conducting some kind of investigation/medical intervention first, such as performing magnetic resonance imaging (85.9%), administrating high-dose corticosteroids (50.2%), or increasing the mean arterial pressure (44.7%). Overall, 90.6% of surgeons believed that CPGs for the management of PND would be useful and 94.4% would be either likely or extremely likely to use these CPGs in their clinical practice. CONCLUSIONS: Most respondents are aware and routinely use CPGs in their practice. Most surgeons performing spine surgeries reported not feeling comfortable managing PND. However, they highly value the creation and are likely to use CPGs in its management.
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Internacionalidad , Enfermedades del Sistema Nervioso/terapia , Neurocirujanos/normas , Atención Perioperativa/normas , Guías de Práctica Clínica como Asunto/normas , Encuestas y Cuestionarios , Estudios Transversales , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/epidemiología , Atención Perioperativa/métodos , Proyectos PilotoRESUMEN
STUDY DESIGN: An ambispective analysis. OBJECTIVE: The aim of this study was to report the global prevalence of specific degenerative cervical pathologies in patients with degenerative cervical myelopathy (DCM) through detailed review of magnetic resonance imaging (MRIs). SUMMARY OF BACKGROUND DATA: DCM encompasses a spectrum of age-related conditions that result in progressive spinal cord injury. METHODS: MRIs of 458 patients (age 56.4â±â11.8, 285 male, 173 female) were reviewed for specific degenerative features, directionality of cord compression, levels of spinal cord compression, and signal changes on sagittal T2-weighted imaging (T2WI) and sagittal T1-weighted imaging (T1WI). Data were analyzed for differences between sex using Chi-square tests and geographic variations using Kruskal-Wallis tests. RESULTS: Spondylosis was frequently present (89.7%) and was commonly accompanied by enlargement of the ligamentum flavum (LF) (59.9%). Single-level disc pathology, ossification of posterior longitudinal ligament (OPLL), and spondylolisthesis had a prevalence of â¼10% each. OPLL was accompanied by spondylosis in 91.7%. Klippel-Feil syndrome was observed in 2.0%. The Asia-Pacific region had more OPLL (29%, Pâ=â3â×â10) and less spondylolisthesis (1.9%, Pâ=â0.002). Females presented more commonly with single-level disc pathology (13.9% vs. 6.7%; Pâ=â0.013), and males with spondylosis (92.3% vs. 85.6%; Pâ=â0.02) and enlargement of LF (61.4% vs. 49.1%; Pâ=â0.01). C5 to C6 was the most frequent maximum compressed site (39.5%) and region for T2WI hyperintensity (38.9%). T2WI hyperintensity more commonly presented in males (82.4% vs. 66.7%; Pâ<â0.001). CONCLUSION: This is the largest report on the prevalence and spectrum of pathology in patients with DCM. Herein, it has been demonstrated that degenerative features are highly interrelated, that females presented with milder MRI evidence of DCM, and that variations exist in the prevalence of pathologies between geographical regions. LEVEL OF EVIDENCE: 2.
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Imagen por Resonancia Magnética , Enfermedades de la Médula Espinal/diagnóstico por imagen , Enfermedades de la Médula Espinal/epidemiología , Enfermedades de la Columna Vertebral/diagnóstico por imagen , Enfermedades de la Columna Vertebral/epidemiología , Adulto , Anciano , Bases de Datos Factuales , Femenino , Salud Global , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Enfermedades de la Médula Espinal/etiología , Enfermedades de la Médula Espinal/patología , Enfermedades de la Columna Vertebral/complicaciones , Enfermedades de la Columna Vertebral/patologíaRESUMEN
OBJECTIVE: We conducted a survey to understand how specific pathologic features on magnetic resonance imaging (MRI) influence surgeons toward an anterior or posterior surgical approach in degenerative cervical myelopathy (DCM). METHODS: A questionnaire was sent out to 6179 AOSpine International members via e-mail. This included 18 questions on a 7-point Likert scale regarding how MRI features influence the respondent's decision to perform an anterior or posterior surgical approach. Influence was classified based on the mean and mode. Variations in responses were assessed by region and training. RESULTS: Of 513 respondents, 51.7% were orthopedic surgeons, 36.8% were neurosurgeons, and the remainder were fellows, residents, or other. In ascending order, multilevel bulging disks, cervical kyphosis, and a high degree of anterior cord compression had a moderate to strong influence toward an anterior approach. A high degree of posterior cord compression had a moderate to strong influence, whereas multilevel compression, ossification of the posterior longitudinal ligament, ligamentum flavum enlargement, and congenital stenosis had a moderate influence toward a posterior approach. Neurosurgeons chose anterior approaches more and posterior approaches less in comparison with orthopedic surgeons (P < 0.01). Of note, 59.8% of respondents were equally comfortable performing multilevel (3 or more levels) anterior and posterior procedures, whereas 61.5% did not feel comfortable in determining the surgical approach based on MRI alone. CONCLUSIONS: Specific DCM pathology influences the choice for anterior or posterior surgical approach. These data highlight factors based on surgeon experience, training, and region of practice. They will be helpful in defining future areas of investigation in an effort to provide individualized surgical strategies and optimize patient outcomes.
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Vértebras Cervicales/cirugía , Toma de Decisiones/fisiología , Desplazamiento del Disco Intervertebral/cirugía , Osificación del Ligamento Longitudinal Posterior/cirugía , Enfermedades de la Médula Espinal/cirugía , Vértebras Cervicales/patología , Descompresión Quirúrgica/métodos , Humanos , Desplazamiento del Disco Intervertebral/patología , Cifosis/cirugía , Imagen por Resonancia Magnética/métodos , Cuello/patología , Cuello/cirugía , Enfermedades de la Médula Espinal/patologíaRESUMEN
BACKGROUND: High quality studies have been challenging to undertake in patients with metastatic epidural spinal cord compression. Nonetheless, in the article "Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study" recently published in the Journal of Clinical Oncology, our team provided convincing evidence that spinal surgery improves overall quality of life in patients with this potentially devastating complication of cancer. Considering that metastatic spinal lesions treated with surgery have the highest mean cost among all oncological musculo-skeletal issues, it is essential to provide high quality data to optimize the therapeutic approaches and cost-effective use of health care resources. MAIN BODY: Although the AOSpine Study provided high quality prospective data, it was primarily limited by the lack of non-operative controls and the relatively small sample size. Given the dearth of medical equipoise and the fundamental difference between patients deemed to be adequate surgical candidates and those who are not amenable to operative intervention, conducting a randomized controlled trial in this patient population was not felt to be ethically or medically feasible. Consequently, the optimal option to overcome limitations of both the lack of controls and the relatively small sample size is through collection of large prospective datasets through rigorously developed and maintained registries. CONCLUSIONS: With the alarming increase in the incidence of cancer in China and China's parallel growing cancer control efforts, China would offer a fantastic platform to set up a national metastatic spinal lesion registry. Such registry would not only enhance metastatic epidural spinal cord compression translational research but also optimize patient care.
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Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/cirugía , Neoplasias de la Columna Vertebral/secundario , China , Humanos , Procedimientos Neuroquirúrgicos , Pronóstico , Estudios Prospectivos , Calidad de Vida , Sistema de Registros , Neoplasias de la Columna Vertebral/cirugía , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: Accurate prediction of surgical outcomes in patients suffering from metastatic epidural spinal cord compression (MESCC) is challenging. This survey aims to obtain expert opinion on which preoperative clinical factors are the most relevant predictors of survival, neurologic, functional, and health-related quality of life (HRQoL). METHODS: Members of AOSpine International were invited to participate in a 15-question electronic survey. Results from the entire sample and differences across geographic regions and between neurosurgeons and orthopedic surgeons were analyzed. Factors endorsed by over 50% of the respondents were considered key predictors. RESULTS: Among AOSpine members, 438 responded. The absence of visceral metastasis (n = 335; 76.48%) and the site of primary tumor (n = 228; 52.05%) were identified as important predictors for survival. Frankel/American Spinal Injury Association grade D or E and the ability to walk were common to neurologic (n = 344; 78.54% and n = 238; 54.34%, respectively); functional (n = 269; 61.42% and n = 243; 55.48%, respectively); and HRQoL outcomes (n = 241; 55.02% and n = 242; 55.25%, respectively). While the absence of bowel/bladder/sexual dysfunction was common to neurologic (n = 260; 59.36%) and HRQoL (n = 229; 52.28%) outcomes, a high Karnofsky/Eastern Cooperative Oncology Group performance status was common to functional (n = 237; 54.11%) and HRQoL (n = 221; 50.46%) outcomes. There was overall consistency across specialities and geographic regions. CONCLUSIONS: Neurosurgeons and orthopedic surgeons and respondents from different geographic regions generally identified similar preoperative clinical factors as key predictors of survival, neurologic, functional, and HRQoL outcomes in surgical MESCC patients. The results of this survey will inform the development of clinical prediction rules for survival and HRQoL in MESCC patients selected for surgery to maximize their clinical relevance.
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Neurocirujanos/estadística & datos numéricos , Cirujanos Ortopédicos/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud , Compresión de la Médula Espinal/mortalidad , Compresión de la Médula Espinal/cirugía , Neoplasias de la Médula Espinal/secundario , Neoplasias de la Médula Espinal/cirugía , Actitud del Personal de Salud , Comorbilidad , Encuestas de Atención de la Salud , Incidencia , Internacionalidad , Cuidados Preoperatorios/métodos , Pronóstico , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Compresión de la Médula Espinal/diagnóstico , Neoplasias de la Médula Espinal/mortalidad , Análisis de Supervivencia , Evaluación de SíntomasRESUMEN
STUDY DESIGN: A retrospective analysis of 169 adult patients operated for a conventional spinal schwannoma from the AOSpine Multicenter Primary Spinal Tumors Database. OBJECTIVE: The aim of this study is to identify risk factors for local recurrence of conventional spinal schwannoma in patients who had surgery. SUMMARY OF BACKGROUND DATA: Schwannomas account for up to 30% of all adult spinal tumors. Total resection is the gold standard for patients with sensory or motor deficits. Local recurrence is reported to be approximately 5% and usually occurs several years after surgery. METHODS: Rates and time of local recurrence of spinal schwannoma were quantified. Predictive value of various clinical factors was assessed, including age, gender, tumor size, affected spinal segment, and type of surgery. Descriptive statistics and univariate regression analyses were performed. RESULTS: Nine (5.32%) out the 169 patients in this study experienced local recurrence approximately 1.7 years postoperatively. Univariate analyses revealed that recurrence tended to occur more often in younger patients (39.33â±â14.58 versus 47.01â±â15.29 years) and in the lumbar segment (55.56%), although this did not reach significance [hazard ratio (HR) 0.96, Pâ=â0.127; and Pâ=â0.195, respectively]. Recurrence also arose in the cervical and sacral spine (22.22%, respectively) but not in the thoracic area. Tumors were significantly larger in patients with recurrence (6.97â±â4.66â cm versus 3.81â±â3.34 âcm), with extent in the cranial caudal direction posing the greatest hazard (HRâ=â1.321, Pâ=â0.002). The location of the tumor, whether epidural, intradural, or both (Pâ=â0.246), was not significantly related to recurrence. Regarding surgical technique, over 4 times as many patients who underwent intralesional resection experienced a recurrence proportionally to patients who underwent en bloc resection (HRâ=â4.178, Pâ=â0.033). CONCLUSION: The pre-operative size of the conventional spinal schwannoma and intralesional resection are the main risk factors for local postoperative recurrence. LEVEL OF EVIDENCE: 3.
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Bases de Datos Factuales , Internacionalidad , Recurrencia Local de Neoplasia/etiología , Neurilemoma/cirugía , Neoplasias de la Médula Espinal/cirugía , Carga Tumoral , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/cirugía , Neurilemoma/diagnóstico , Estudios Retrospectivos , Factores de Riesgo , Neoplasias de la Médula Espinal/diagnóstico , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management. PATIENTS AND METHODS: One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively. RESULTS: Median survival time was 7.7 months. The 30-day and 12-month mortality rates were 9% and 62%, respectively. There was improvement at 6 months postoperatively for ambulatory status (McNemar test, P < .001), lower extremity and total motor scores (Wilcoxon signed rank test, P < .001), and at 6 weeks and 3, 6, and 12 months for Oswestry Disability Index, EQ-5D, and pain interference (paired t test, P < .013). Moreover, at 3 months after surgery, the ASIA impairment scale grade was improved (Stuart-Maxwell test P = .004). SF-36 scores improved postoperatively in six of eight scales. The incidence of wound complications was 10% and 2 patients required a second surgery (screw malposition and epidural hematoma). CONCLUSION: Surgical intervention, as an adjunct to radiation and chemotherapy, provides immediate and sustained improvement in pain, neurologic, functional, and HRQoL outcomes, with acceptable risks in patients with a focal symptomatic MESCC lesion who have at least a 3 month survival prognosis.
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Compresión de la Médula Espinal/cirugía , Neoplasias de la Columna Vertebral/secundario , Neoplasias de la Columna Vertebral/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Compresión de la Médula Espinal/etiología , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
STUDY DESIGN: Systematic review. OBJECTIVE: To identify risk factors and preventive methods for wound complications and instrumentation failure after metastatic spine surgery. SUMMARY OF BACKGROUND DATA: We focused on two postoperative complications of metastatic spine tumor surgery: wound complications and instrumentation failure and preventive measures. METHODS: We performed a systematic review of the literature from 1980 to 2015. The articles were analyzed for the presence of documented infection and/or wound complications and instrumentation failure. RESULTS: Forty articles met our inclusion criteria for wound complications and prevention. There is very low level of evidence that preoperative radiation, preoperative neurological deficit, revision procedures, and posterior approaches can contribute to wound complications (infections, wound dehiscence). There is very low level of evidence that plastic surgery soft tissue reconstruction, intrawound vancomycin powder, and percutaneous pedicle screws may prevent postoperative wound complications. Fourteen articles met our inclusion criteria for instrumentation failure. There is very low level of evidence that constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resection can contribute to implant failures. CONCLUSION: ⢠For patients undergoing revision metastatic spine tumor surgery, plastic surgery should perform the soft tissue reconstruction (strong recommendation/very low quality of evidence).⢠For patients undergoing metastatic spine tumor surgery, plastic surgery may perform immediate soft tissue reconstruction (weak recommendation/very low quality of evidence).⢠For patients undergoing metastatic spine tumor surgery, intrawound vancomycin can be applied to decrease the risk of postoperative wound infections (weak recommendation/very low quality of evidence).⢠For patients undergoing metastatic spine tumor surgery, percutaneous pedicle screws can be placed to decrease the risk of postoperative wound complications (weak recommendation/very low quality of evidence).⢠Instrumentation failure risk factors include constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resections (weak recommendation/very low quality of evidence). LEVEL OF EVIDENCE: N/A.
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Procedimientos Ortopédicos/efectos adversos , Neoplasias de la Columna Vertebral/cirugía , Infección de la Herida Quirúrgica/prevención & control , Antibacterianos/uso terapéutico , Humanos , Procedimientos Ortopédicos/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos de Cirugía Plástica/métodos , Neoplasias de la Columna Vertebral/secundario , Infección de la Herida Quirúrgica/etiología , Resultado del Tratamiento , Vancomicina/uso terapéuticoRESUMEN
Spinal metastases are increasingly becoming a focus of attention with respect to treating with locally "ablative" intent, as opposed to locally "palliative" intent. This is due to increasing survival rates among patients with metastatic disease, early detection as a result of increasing availability of spinal MRI, the recognition of the oligometastatic state as a distinct sub-group of favorable metastatic patients and the advent of stereotactic body radiotherapy (SBRT). Although conventionally fractionated radiation therapy has been utilized for decades, the rates of complete pain relief and local control for complex tumors are sub-optimal. SBRT has the advantage of delivering high total doses in few fractions (typically, 24 Gy in 1 or 2 fractions to 30-45 Gy in 5 fractions) that can be considered "ablative". With mature clinical experience emerging among early adopters, we are realizing beyond efficacy the limitations of spine SBRT. In particular, toxicities such as vertebral compression fracture, and epidural disease progression as the most common pattern of local tumor progression. As a result, the multidisciplinary evaluation of cases prior to SBRT is emphasized with the intent to identify patients who could benefit from surgical stabilization or down-staging of epidural disease. The purpose of this review is to provide an overview of the current literature with respect to outcomes, technical details for safe delivery, patient selection criteria, common and uncommon side effects of therapy, and the increasing use of minimally invasive surgical techniques that can improve both safety and local control.