Risks for prolonged mechanical ventilation and reintubation after cervical malignant tumor surgery: a nested case-control study.

PURPOSE: Prolonged mechanical ventilation (PMV) and reintubation are among the most serious postoperative adverse events associated with malignant cervical tumors. In this study, we aimed to clarify the incidence, characteristics, and risk factors for PMV and reintubation in target patients. METHODS: This retrospective nested case-control study was performed between January 2014 and January 2020 at a large spinal tumor center in China. Univariate analysis was used to identify the possible risk factors associated with PMV and reintubation. Logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) with covariates of a probability < 0.05 in univariate analysis. RESULTS: From a cohort of 560 patients with primary malignant (n = 352) and metastatic (n = 208) cervical tumors, 27 patients required PMV and 20 patients underwent reintubation. The incidence rates of PMV and reintubation were 4.82% and 3.57%, respectively. Three variables (all p < 0.05) were independently associated with an increased risk of PMV: Karnofsky Performance Status < 50 compared to ≥ 80, operation duration ≥ 8 h compared to < 6 h, and C4 nerve root encased by the tumor. Longer operative duration and preoperative hypercapnia (all p < 0.05) were independent risk factors for postoperative reintubation, both of which led to longer length of stay (32.6 ± 30.8 vs. 10.7 ± 5.95 days, p < 0.001), with an in-hospital mortality of 17.0%. CONCLUSION: Our results demonstrate the risk factors for PMV or reintubation after surgery for malignant cervical tumors. Adequate assessment, early detection, and prevention are necessary for this high-risk population.

Combined replantation of the posterior arch of the atlas and bilateral axial lamina in the treatment of intradural schwannoma: a case report.

Background: Laminotomy and laminar replantation have emerged as novel treatment modalities for intraspinal tumors, aiming to minimize postoperative complications and retain spinal mobility. However, existing research predominantly emphasizes their application in the thoracolumbar spine. The unique anatomy of the atlantoaxial segments necessitates surgical techniques that differ from those used in other spinal regions, and the clinical effect of such procedure remains unknown. Case presentation: A 61-year-old male patient with intradural schwannoma at the atlantoaxial level was operated on. The patient underwent posterior laminectomy, as well as a combined replantation of the posterior arch of the atlas and bilateral axial laminae. Postoperatively, the patient experienced significant neurological improvement, with no deformities or instability on the radiological assessments during the follow-up. Conclusion: Laminotomy with combined replantation of the posterior arch of the atlas and bilateral axial lamina emerges as an effective approach for managing intraspinal tumors at the atlantoaxial level. This technique not only offers ample operating space but also restores the stability of the spinal canal. Moreover, it preserves the mobility of the atlantoaxial segment, minimizes impact on adjacent segments, and mitigates the formation of postoperative fibrosis.

Intralesional curettage and surgical adjuvants in the treatment of giant cell tumor of bone: meta-analysis and systematic review.

BACKGROUND: The ideal treatment for giant cell tumor of bone (GCTB) is still controversial. Various surgical adjuvants have been introduced following intralesional curettage to improve local control rates. However, findings from relevant studies are inconsistent, and no consensus has been reached. The purpose of this study is to determine what intraoperative adjuvant is effective in decreasing the recurrence of GCTB. METHODS: We performed a systematic review and meta-analysis of articles published in the PubMed and Embase electronic databases which assessed the recurrence rate of GCTB following intralesional curettage with or without various surgical adjuvants. Two authors independently evaluated all publications. Meta-analysis was performed with Stata/MP (Version 17.0, StataCorp LLC, TX, USA) and Review Manager (RevMan, Version 5.4.1, The Cochrane Collaboration, 2020). Pooled risk ratio (RR) was used for analysis, with P values less than 0.05 considered statistically significant. RESULTS: Twenty-four studies involving 2,579 patients were included in this analysis. The overall recurrence rates for patients treated with or without high-speed burring (HSB) are 11.9% (26/218) and 47.7% (92/193), respectively. The pooled RR for tumor recurrence is 0.33 (95% CI: 0.22 to 0.49, P<0.001). In the meanwhile, the overall recurrence rates for patients treated with or without chemical adjuvants are 23.5% (77/328) and 26.1% (73/280), respectively, with a pooled RR of 0.84 (95% CI: 0.63 to 1.10, P=0.89). Additionally, the overall recurrence rates for patients treated with or without polymethyl methacrylate (PMMA) are 20.4% (205/1,006) and 33.4% (314/939), respectively, with a pooled RR of 0.59 (95% CI: 0.50 to 0.69, P<0.001). CONCLUSIONS: Intraoperative application of HSB or PMMA has an additional antitumor effect, while the use of phenol or H2O2 fails to make any significant difference (PROSPERO: CRD42022344262).

Surgical Strategy for Recurrent Giant Cell Tumor in the Thoracolumbar Spine.

OBJECTIVE: Recurrent giant cell tumor (RGCT) of the spine represents a clinical challenge for surgeons, and the treatment strategy remains controversial. This study aims to describe the long-term follow-up outcomes and compare the efficacy of en bloc spondylectomy versus piecemeal spondylectomy in treating RGCT of the thoracolumbar spine. METHODS: A total of 32 patients with RGCT of the thoracolumbar spine treated from June 2012 to June 2019 were retrospectively reviewed. A total of 15 patients received total en bloc spondylectomy (TES) with wide or marginal margin while 17 patients received total piecemeal spondylectomy (TPS) with intralesional margin. Postoperative Eastern Cooperative Oncology Group Performance Score (ECOG-PS), Frankel classification and recurrence-free survival (RFS) were evaluated after surgery. Survival curves were estimated by the Kaplan-Meier method and differences were analyzed with the log-rank test. Multivariate analysis was performed with Cox regression to identify the independent prognostic factors affecting RFS. RESULTS: During a median follow-up of 41.9 ± 17.5 months, all patients with compromised neurologic functions exhibit significant improvement, with the mean ECOG-PS decreasing from 1.5 ± 1.3 to 0.13 ± 0.3 (p < 0.05). Among the 17 patients treated with TPS, eight patients developed local recurrence after a median time of 15.9 ± 6.4 months and four patients died from progressive disease. On the other hand, local recurrence were well managed with TES, since only one out of 15 patients experienced local relapse and all patients are alive with satisfied function at the latest follow-up. The median RFS for patients receiving TES and TPS are 75.0 months (95% CI: 67.5-82.5 m) and 38.3 months (95% CI: 27.3-49.3 m) respectively (p = 0.008). Multivariate analysis shows that the Ki67 index (p = 0.016), resection mode (p = 0.022), and denosumab (p = 0.039) are independent risk factors affecting RFS. CONCLUSIONS: TES with wide/marginal margin should be offered to patients with RGCT whenever feasible, given its long-term benefits in local control and symptom alleviation. Additionally, patients with lower Ki67 index and application of denosumab tend to have a better prognosis.

Comparison of Single or Double Titanium Mesh Cage for Anterior Reconstruction After Total En Bloc Spondylectomy for Thoracic and Lumbar Spinal Tumors.

OBJECTIVE: To compare the clinical efficacy of anterior column reconstruction using single or double titanium mesh cage (TMC) after total en bloc spondylectomy (TES) of thoracic and lumbar spinal tumors. METHODS: A retrospective cohort study was performed involving 39 patients with thoracic or lumbar spinal tumors. All patients underwent TES, followed by anterior reconstruction and screw-rod instrumentation via a posterior-only procedure. Twenty-two patients in group A were treated with a single TMC to reconstruct the anterior column, whereas 17 patients in group B were reconstructed with double TMCs. RESULTS: The overall follow-up is 20.5 ± 4.6 months. There is no significant difference between the 2 groups regarding age, sex, body mass index, tumor location, operative time, and intraoperative blood loss. The time for TMC placement was significantly shortened in the double TMCs group (5.2 ± 1.3 minutes vs. 15.6 ± 3.3 minutes, p = 0.004). Additionally, postoperative neural complications were significantly reduced with double TMCs (5/22 vs. 0/17, p = 0.046). The kyphotic Cobb angle and mean intervertebral height were significantly corrected in both groups (p ≤ 0.001), without obvious loss of correction at the last follow-up in either group. The bone fusion rates for single TMC and double TMCs were 77.3% and 76.5%, respectively. CONCLUSION: Using 2 smaller TMCs instead of a single large one eases the placement of TMC by shortening the time and avoiding nerve impingement. Anterior column reconstruction with double TMC is a clinically feasible, and safe alternative following TES for thoracic and lumbar tumors.

A Novel Free-hand Technique of Pedicle Screw Placement in the Lumbar Spine: Accuracy Evaluation and Preliminary Clinical Results.

OBJECTIVE: Pedicle screw implantation is the most common technique to achieve stability during spinal surgeries. Current methods for locating the entry point do not have a quantified criteria and highly rely on the surgeons' experience. Therefore, we aim to propose a quantified pedicle screw placement technique in the lumbar spine and to investigate its accuracy and safety in clinical practice. METHODS: We conducted a retrospective study involving 110 patients who received spinal surgery in our hospital from August 2018 to August 2021. All patients included had herniation of a single lumbar disc and were consistently treated with posterior discectomy, inter-body fusion, and transpedicular internal fixation. For 54 patients in the observation group, the pedicle screws were placed with our technique, which is located at 4 mm below the superior edge of the transverse process in line with the lateral margin of the superior articular process. For 56 patients in the control group, pedicle screws were placed according to the traditional crista lambdoidalis method. Comparisons were made in terms of the operation time, blood loss, time for exposure, the accuracy of placement, and postoperative complications. Furthermore, we applied our method to 64 patients with indistinguishable crista lambdoidalis and evaluated the accuracy of screw placement and clinical outcomes according to the visual analogue scale (VAS) and the Japanese Orthopaedic Association (JOA) score. RESULTS: There was no significant difference in intraoperative bleeding, accuracy of placement, and postoperative complications between our technique and the traditional crista lambdoidalis method (P > 0.05). However, the exposure time before screw placement (12.8 ± 0.3 vs. 17.4 ± 0.3, P = 0.001) and the total surgery time (97.2 ± 1.9 vs 102.3 ± 0.9, P = 0.020) were significantly shortened with our method. Additionally, in cases with indistinguishable crista lambdoidalis, our technique showed satisfying accuracy, with 97.6% screws placed in appropriate trajectory on the first attempt and all screws eventually positioned in the safe zone according to the Gertzbein-Robbins grading. All patients experienced steady improvement after surgery. CONCLUSION: Placing pedicle screws at 4 mm below the superior edge of the transverse process in line with the lateral margin of the superior articular process is a viable pedicle screw placement method. With this method, we observed a higher success rate and shorter operation time. In addition, this method can be applied in cases with indistinguishable crista lambdoidalis, and have satisfied success rate and clinical outcome.

An innovative virtual reality training tool for the pre-hospital treatment of cranialmaxillofacial trauma.

Virtual reality (VR) surgery using the High Technology Computer Corporation Very Immersive Virtual Experience professional 2(HTC VIVE Pro2) suite is a multi-sensory, holistic surgical training experience. A multimedia combination including videos and three-dimensional interaction in VR has been developed to enable trainees to experience a realistic battlefield environment. The innovation allows trainees to interact with the individual components of the cranialmaxillofacial(CMF) anatomy and apply surgical instruments while watching close-up stereoscopic three-dimensional videos of the surgery. In this study, a novel training tool for the pre-hospital treatment of CMF trauma based on immersive virtual reality (iVR) was developed and validated. Twenty-five CMF surgeons evaluated the application for face and content validity. Using a structured assessment process, the surgeons commented on the content of the developed training tool, its realism and usability and the applicability of VR surgery for CMF trauma rescue simulation training. The results confirmed the applicability of VR for delivering training in the pre-hospital treatment of CMF trauma. Modifications were suggested to improve the user experience and interactions with the surgical instruments. This training tool is ready for testing with surgical trainees.

Current research and management of undifferentiated pleomorphic sarcoma/myofibrosarcoma.

Undifferentiated pleomorphic sarcoma (UPS), once termed as malignant fibrous histiocytoma, has always been diagnosed exclusively in clinical practice because it lacks any defined resemblance to normal mesenchymal tissue. Although myxofibrosarcoma (MFS) has been separated from UPS due to its fibroblastic differentiation with myxoid stroma, UPS and MFS are still identified as a sarcoma group in terms of molecular landscapes. In this review article, we will describe the associated genes and signaling pathways involved in the process of sarcoma genesis and make a summary of conventional management, targeted therapy, immunotherapy, and some novel potential treatments of UPS/MFS. With the progressive advancements in medical technology and a better understanding about the pathogenic mechanism of UPS/MFS in the coming decades, new lights will be shed on the successful management of UPS/MFS.

AMTB, a TRPM8 antagonist, suppresses growth and metastasis of osteosarcoma through repressing the TGFß signaling pathway.

Since its first identification in prostate cancers and prostate tissues, transient receptor potential melastatin-subfamily member 8 (TRPM8) is subsequently found to be overexpressed in a wide range of cancers and is shown to be implicated in tumorigenesis and tumor progression. Here, we used N-(3-aminopropyl)-2-[(3-methylphenyl) methoxy] -N-(2-thienylmethyl) benzamide hydrochloride (AMTB), a specific TRPM8 antagonist, to explore its antitumoral effect on osteosarcoma. We find that AMTB suppresses osteosarcoma cell proliferation, metastasis and induces cellular apoptosis. Xenograft model in nude mice experiments also define that AMTB can increase the sensitivity of tumor cells to cisplatin, the cytotoxic chemotherapeutic regimens in treating osteosarcoma. Molecularly, AMTB specifically antagonizes TRPM8 which is upregulated in osteosarcoma and its expression level in osteosarcoma tissues is negatively related to patients' prognosis. Finally, RNA sequencing analysis was performed to explore the mechanism underlying the antitumoral effect of AMTB on osteosarcoma cells and the results prove that AMTB suppresses the Transforming Growth Factor ß (TGFß) signaling pathway. Our study provides evidence that TRPM8 could be a potential therapeutic target and AMTB can suppress growth and metastasis of osteosarcoma cells through repressing the TGFß signaling pathway and increase the sensitivity of tumor cells to cisplatin.

Symptomatic spinal metastases from neuroendocrine neoplasms: surgical outcomes and prognostic analysis.

OBJECTIVES: In this article, we investigated the efficiency of surgery in treating symptomatic spinal metastases from neuroendocrine neoplasms and performed univariate analysis for identification of possible prognostic factors. METHODS: A retrospective study was performed, enrolling a total of 19 patients who received surgeries in our center for symptomatic spinal metastases from neuroendocrine neoplasms (NEN). The Kaplan-Meier method was adopted to estimate overall survival (OS) and recurrence free survival (RFS). Univariate analysis was performed for identification of possible prognostic factors. RESULTS: All patients recruited displayed stable recovery after surgical intervention, with a median OS of 27.3 months (95% Confidence Interval: 16.4-38.1 months) and a median RFS of 23.0 months (95% Confidence Interval: 12.1-33.8 months). Postoperatively, 15 patients exhibited improved neurological function based on the Frankel classification, while 16 patients experienced significant pain relief, with mean visual analog scale (VAS) score decreasing from 7.47 ± 2.32-2.47 ± 1.25 (p < 0.05). Univariate analysis revealed that the presence of visceral metastases (p = 0.034) and extraspinal bone metastases (p = 0.016) are both related with poor prognosis. Additionally, well histologic differentiation (p = 0.010) and administration of postoperative octreotide (p = 0.041) or bisphosphonate (p = 0.023) are all indicators for better outcome. CONCLUSIONS: Surgery is an efficient option for treating symptomatic spinal metastases from NEN due to its immediate and assured benefits in pain alleviation, restoration of function and stability reconstruction.

Surgical outcomes and prognostic factors for patients with gastric cancer spinal metastasis.

PURPOSE: To investigate the outcome and prognostic factors of surgery in treating gastric cancer spinal metastasis (GCSM). PATIENTS AND METHODS: A total of 17 patients with GCSM who have undertaken spinal surgeries have been identified. Kaplan-Meier method and univariate analysis are adopted to investigate the prognostic factors affecting overall survival (OS) and progression-free survival (PFS). RESULTS: The median PFS and OS are 11.3 months (95% CI: 7.8-14.9 months) and 11.9 months (95% CI: 8.4-15.4 months), respectively. Postoperatively, all patients had substantial pain relief, with mean visual analog scale score descending from 6.6±1.6 to 3.4±1.2. Meanwhile, patients also showed improved neurological functions, with 8 of them having improvements of at least one level in Frankel classification. Univariate analysis presented that patients with carcinoembryonic antigen (CEA)<6 µg/L (p=0.020), lactate dehydrogenase (LDH)<300 U/L (p=0.012), alkaline phosphatase (ALP)<200 U/L (p=0.007), and Tokuhashi score>6 (p=0.027) show longer OS. Moreover, application of bone cement, low level of ALP (<200 U/L), and LDH (<300 U/L) are associated with longer PFS (p<0.05). CONCLUSIONS: Surgery is an efficient option in treating GCSM, due to its efficacy in pain alleviation, function restoration, and stability reconstruction. Low levels of CEA, LDH, ALP, and high Tokuhashi score (>6) are all favorable factors for better OS, whereas low levels of LDH, ALP, and application of bone cement are related with longer PFS.