Percutaneous Cementation for Improvement of Pain and Function for Osteolytic Pelvic Metastasis: A Systematic Review.

INTRODUCTION: Pelvic metastasis is a common presentation among patients presenting with skeletal metastasis. Image-guided percutaneous cementation of these lesions is becoming increasingly popular for the treatment of these lesions. The objective of this study was to conduct a systematic review that investigates clinical outcomes after percutaneous cementation for pelvic metastasis. METHODS: A systematic review was registered with International Prospective Register of Systematic Reviews and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed, SCOPUS, and Ovid MEDLINE databases. All level I to IV clinical studies published in the English language investigating the clinical outcomes after percutaneous cementation for pelvic metastasis were included. RESULTS: Fourteen studies with 579 patients (278 men, 301 women) and 631 metastatic pelvic lesions were included in the study. The mean follow-up range was 0.7 to 26.4 months. Percutaneous cementation alone was performed in 441 patients (76.2%). Supplemental ablative procedures were performed in 77 patients (13.3%), and supplemental internal fixation using cannulated screws was performed in 107 patients (18.5%). Twelve studies with 430 patients (74.2%) reported pain-related and/or functional outcome scores, of which all studies reported overall clinically notable improvement at short-term follow-up. All studies reported periprocedural complications. Local cement leakage was the most common complication (162/631 lesions, 25.7%) followed by transient local pain (25/579 patients, 4.3%). There were no reported cases of major complications. Seven patients (1.2%) underwent re-intervention for persistent symptoms. CONCLUSIONS: Percutaneous cementation may be an effective method for treating pain and function related to pelvic metastasis. The most common complication was cement leakage surrounding the lesion. The rates of major complications were low, and most complications appeared minor and transient. Additional prospective studies are needed to further assess the efficacy of this procedure. LEVEL OF EVIDENCE: IV, systematic review of level I to IV therapeutic studies.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery.

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.

A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery.

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.

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

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.

Response to Letter Regarding "Predictive Value of Preoperative Serum Albumin in Patients With Metastatic Spine Diseases: A Statistical Comment".

We thank the authors for their interest in and commentary on "Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease." We appreciate the opportunity to respond to their comments herein.

Customized 3-dimensional-printed Vertebral Implants for Spinal Reconstruction After Tumor Resection: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To examine the outcomes of customized 3-dimensional (3D) printed implants for spinal reconstruction after tumor resection. SUMMARY OF BACKGROUND DATA: Various techniques exist for spinal reconstruction after tumor resection. Currently, there is no consensus regarding the utility of customized 3D-printed implants for spinal reconstruction after tumor resection. MATERIALS AND METHODS: A systematic review was registered with PROSPERO and performed according to "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines. All level I-V evidence studies reporting the use of 3D-printed implants for spinal reconstruction after tumor resection were included. RESULTS: Eleven studies (65 patients; mean age, 40.9 ± 18.1 y) were included. Eleven patients (16.9%) underwent intralesional resections with positive margins and 54 patients (83.1%) underwent en bloc spondylectomy with negative margins. All patients underwent vertebral reconstruction with 3D-printed titanium implants. Tumor involvement was in the cervical spine in 21 patients (32.3%), thoracic spine in 29 patients (44.6%), thoracolumbar junction in 2 patients (3.1%), and lumbar spine in 13 patients (20.0%). Ten studies with 62 patients reported perioperative outcomes radiologic/oncologic status at final follow-up. At the mean final follow-up of 18.5 ± 9.8 months, 47 patients (75.8%) had no evidence of disease, 9 patients (14.5%) were alive with recurrence, and 6 patients (9.7%) had died of disease. One patient who underwent C3-C5 en bloc spondylectomy had an asymptomatic subsidence of 2.7 mm at the final follow-up. Twenty patients that underwent thoracic and/or lumbar reconstruction had a mean subsidence of 3.8 ± 4.7 mm at the final follow-up; however, only 1 patient had a symptomatic subsidence that required revision surgery. Eleven patients (17.7%) had one or more major complications. CONCLUSION: There is some evidence to suggest that using customized 3D-printed titanium or titanium alloy implants is an effective technique for spinal reconstruction after tumor resection. There is a high incidence of asymptomatic subsidence and major complications that are similar to other methods of reconstruction. LEVEL OF EVIDENCE: Level V, systematic review of level I-V studies.

Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease.

STUDY DESIGN: Retrospective review of a prospectively collected national database. OBJECTIVES: To determine the association between preoperative serum albumin levels and perioperative adverse events (AEs) following vertebral corpectomy and posterior stabilization for metastatic spine disease. METHODS: The 2010 to 2019 American College of Surgeons' National Surgical Quality Improvement (ACS-NSQIP) database was used to identify all patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Receiver operative characteristic (ROC) curve analysis was used to determine preoperative serum albumin cut-off values for predicting perioperative AEs. Low preoperative serum albumin was defined as serum albumin below this cut-off value. RESULTS: A total of 301 patients were included in the study. ROC curve analysis demonstrated serum albumin < 3.25 g/dL as a cut-off value for predicting perioperative AEs. The low serum albumin group had a higher overall perioperative AEs (P = .041), longer post-operative LOS (P < .001), higher 30-day reoperation rate (P = .014), and a higher in-hospital mortality rate (P = .046). Multivariate analysis demonstrated that low preoperative serum albumin was associated with higher perioperative AEs. CONCLUSIONS: Low serum albumin level is associated with higher perioperative AEs, longer postoperative LOS, and higher rates of 30-day reoperation and in-hospital mortality among patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Strategies to improve preoperative nutritional status in patients undergoing this procedure may improve these perioperative outcome measures within this surgical population. LEVEL OF EVIDENCE: III.

Anterior column realignment (ACR) for focal kyphotic spinal deformity using an anterior to psoas approach and anterior longitudinal ligament release.

Background: The anterior-to-psoas (ATP) approach to the lumbar spine has been proposed as an alternative to the transpsoas approach for approaching the disc space without dissecting through the psoas muscle, thus decreasing the risk of injury to the lumbar plexus. There are no prior studies that evaluates the clinical application of anterior longitudinal ligament (ALL) release and anterior column realignment (ACR) using the ATP approach. The objective of this study was to describe and evaluate the safety of ACR using an ATP approach with release of both the ALL and bilateral annulus for correction of a focal kyphotic lumbar deformity. Methods: A retrospective analysis of fourteen consecutive patients at a single institution between January 2017 and December 2019 of patients undergoing ACR using an ATP approach for lumbar flatback syndrome with focal kyphotic lumbar deformity by a single surgeon was performed. Primary outcome measures were pre- and postoperative radiographic parameters. Secondary outcome measures were perioperative adverse events (AEs), 30-day readmissions/reoperations, discharge disposition, post-operative length of stay (LOS), and radiographic complications. Results: Fourteen consecutive patients (mean age 67.0±3.9 years, 8 males, 6 females) with 15 total ACR levels were included in the study. A grade 1 posterior column osteotomy (PCO) with posterior instrumentation was performed at all ACR levels. L2-L3 ACR was performed in nine patients, L3-L4 in four patients, and L4-L5 in two patients. Mean preoperative disk lordotic angle at the ACR level was 5.4°±5.9° of kyphosis. Mean increase in postoperative disk lordotic angle was 24.0°±8.5° at a mean follow-up of 34.0±23.4 months. Conclusions: ACR can be performed with a complete ALL release under direct visualization using the ATP approach. This technique can be a safe and effective method for achieving substantial correction of a focal kyphotic deformity within the lumbar spine.

Vascular injury risk stratification for lateral lumbar interbody fusion (LLIF) at L4-L5: a morphometric study using magnetic resonance imaging.

Background: Proper vascular injury risk stratification (VIRS) methods for L4-L5 lateral lumbar interbody fusion (LLIF) surgery have not been well-described. The objective of this study was to propose a novel VIRS method for L4-L5 LLIF surgery via the transpsoas approach. Methods: Axial magnetic resonance imaging (MRI) of adult patients were obtained and analyzed. The VIRS scores were assessed using anterior disc line to posterior vessel wall distance, the disc vessel angle (DVA), and the disc edge to vessel distance at the level of L4-L5 disc space. Results: Ninety-one consecutive adult patients were included in the study. The right common iliac vein (CIV) had a high risk of injury with both right- and left-sided approaches. The left CIV had a moderate risk with a left-sided approach when the iliocaval confluence was above the L4-L5 disc space but had a high risk when the confluence was at the L4-L5 disc space. The left CIV had a high risk with a right-sided approach when the confluence was above the L4-L5 disc space but had a moderate risk when the confluence was at the L4-L5 disc space. The inferior vena cava (IVC) had a high risk with both right- and left-sided approaches. The aorta had a moderate risk regardless of the right or left-sided approaches. The left common iliac artery (CIA) had a moderate risk with a right-sided approach and a low risk with a left-sided approach. The right CIA had a low risk with both right- and left-sided approaches. Conclusions: There are significant vascular anatomic variations at the L4-L5 disc level and a proper VIRS can be performed utilizing a combination of anterior disc line to posterior vessel wall distance, DVA, and disc edge to vessel distance, on the axial MRI.

Obesity and perioperative adverse events in patients undergoing complex revision surgery for the thoracolumbar spine.

BACKGROUND: There are no previous studies that evaluate the effect of obesity on patients undergoing complex revision thoracolumbar spine surgery. The primary objective was to determine the relationship between obesity and perioperative adverse events (AEs) with patients undergoing complex revision thoracolumbar spine surgery while controlling for psoas muscle index (PMI) as a confounding variable. The secondary objective was to determine the relationship between obesity and 30-day readmission rates, 30-day re-operation rates, rate of discharge to a facility, and post-operative length of stay (LOS). METHODS: Between May 2016 and February 2020, a retrospective analysis of individuals undergoing complex revision surgery of the thoracolumbar spine was performed at a single institution. Obesity was defined as BMI ≥ 30.0 kg/m2. PMI < 500 mm2/m2 for males and < 412 mm2/m2 for females were used to define low muscle mass. A Spine Surgical Invasiveness Index (SSII) > 10 was used to define complex revision surgery. A multivariable logistic regression model was used to ascertain the effects of low muscle mass, obesity, age, and gender on the likelihood of the occurrence of any AE. RESULTS: A total of 114 consecutive patients were included in the study. Fifty-four patients were in the obese cohort and 60 patients in the non-obese cohort. There was not a significant difference in perioperative outcomes of both the obese and non-obese patients. There were 22 obese patients (40.7%) and 33 non-obese patients (55.0%) that experienced any AE (p = 0.130). Multivariable analysis demonstrated that individuals with low muscle mass had a significantly higher likelihood for an AE than individuals with normal or high muscle mass (OR: 7.53, 95% CI: 3.05-18.60). Obesity did not have a significant effect in predicting AEs. CONCLUSIONS: Obesity is not associated with perioperative AEs, 30-day readmission rates, 30-day re-operation rates, rate of discharge to a facility, or post-operative length of stay (LOS) among patients undergoing complex revision thoracolumbar spine surgery. LEVEL OF EVIDENCE: III.

Sarcopenia predicts perioperative adverse events following complex revision surgery for the thoracolumbar spine.

BACKGROUND CONTEXT: Sarcopenia measured by psoas muscle index (PMI) has been shown to predict perioperative mortality and adverse events (AEs) after various surgical procedures. However, this relationship has not been studied in complex revision thoracolumbar spine surgery. PURPOSE: This study aimed to determine the relationship between sarcopenia and perioperative AEs among patients undergoing complex revision thoracolumbar spine surgery. STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: A retrospective analysis was performed at a single institution between May 2016 and February 2020 of patients undergoing complex revision thoracolumbar spine surgery by three board certified fellowship-trained orthopaedic spine surgeons. OUTCOME MEASURES: Perioperative adverse events including postoperative anemia requiring transfusion, cardiac complication, sepsis, wound complication, delirium, intra-operative dural tear, acute kidney injury, pneumonia, urinary tract infection, urinary retention, epidural hematoma, and deep vein thrombosis. Secondary outcome measures were 30-day readmission rates, 30-day re-operation rates, in-hospital mortality rates, discharge disposition, and postoperative length of stay (LOS). METHODS: Sarcopenia was analyzed using PMI, calculated at the L3 vertebral body measured on preoperative magnetic resonance imaging (MRI) or computed tomography (CT) normalized to height2 (mm2/m2). Receiver operating characteristic (ROC) curve analysis and Youden index were used to determine gender-specific PMI cut-off values for predicting perioperative AEs. Sarcopenia was defined as PMI below the cut-off values. Complex revision surgery was defined as Spine Surgical Invasiveness Index >10. RESULTS: A total of 114 consecutive patients were included in the study. ROC curve analysis demonstrated PMI <500 mm2/m2 for males and <412 mm2/m2 for females as predictors for perioperative AEs. 49 patients were in the sarcopenia cohort and 65 patients in the nonsarcopenia cohort. The sarcopenia group had higher overall perioperative AEs (75.5% vs 27.7%, p<.001) and individual AEs including: postoperative anemia requiring transfusion, wound complication, delirium, acute kidney injury, pneumonia, urinary tract infection, and deep vein thrombosis. The sarcopenia group had higher 30-day reoperation rate (14.3% vs 3.1%, p=.037), 30-day readmission rate (16.3% vs 3.1%, p=.018), rate of discharge to a facility (83.7% vs 50.8%, p<.001), and longer length of stay (LOS) (7.3±4.2 days vs 5.6±3.5 days, p=.023). CONCLUSIONS: Sarcopenia measured by PMI is associated with higher perioperative AEs, 30-day readmission rates, 30-day reoperation rates, rate of discharge to a facility, and longer LOS among patients undergoing complex revision thoracolumbar spine surgery.

Decreased radiation exposure using pulsed fluoroscopy and a detachable pedicle marker and probe to place pedicle screws: a comparison to current fluoroscopy techniques and CT navigation.

STUDY DESIGN: Quality improvement evaluation with retrospective analysis. OBJECTIVES: To compare a technique to place pedicle screws (PS) using a novel detachable pedicle marker and probe (DPMP) and pulsed fluoroscopy (PF) vs. conventional technique utilizing PF with standard instruments (SI) and O-arm. Spinal fusion with pedicle screw instrumentation (PSI) is the mainstay in treatment of spinal deformities. Reports suggest that CT navigated (O-arm) PS placement is more accurate than fluoroscopy. However, these studies have not considered the increased radiation exposure associated with CT. METHODS: Thirty-six patients with spinal deformity had PSI using PF and DPMPs. Accuracy of PS placement and radiation data from 14 dosimeters placed on the patient and around the operating room was analyzed. Results were compared to published data. RESULTS: Mean fluoroscopic time was 13.4 s (range 6.0-32.4), and the mean cumulative dose was 3.1 mGy (range 0.2-16.4). Median estimated effective dose to the patient was 0.22 mSv (range 0.0-0.7). The effective dose of radiation was reduced by 80% (0.22 mSv vs. 1.11 mSv) compared to low-dose O-arm. The surgical team did not receive any detectable radiation. The seconds of PF used to assist and confirm placement of PSs was reduced to 1.2 s/level compared to previous reports of 4.49 s/level using SIs. DPMPs reduced fluoroscopy to 0.84 s/PS compared to 7.36 s/PS using SIs to assist and confirm PS placement. PSs were accurately placed in 561 of 576 (97.4%), which is comparable to O-arm and fluoroscopy with SIs. CONCLUSIONS: PS placement using PF and DPMPs to assist and confirm PS placement lowers radiation exposure to the patient and surgical team without compromising accuracy compared to O-arm and fluoroscopy with SIs. LEVEL OF EVIDENCE: Therapeutic, Level IV (Retrospective case series, historical control).

Generation of patient-derived tumor xenografts from percutaneous tumor biopsies in children with bone sarcomas.

One of the limitations of performing percutaneous biopsies in patients with bone sarcomas is the small amount of tumor that can be obtained for research purposes. Here, we describe our experience developing patient-derived tumor xenografts (PDXs) using percutaneous tumor biopsies in children with bone sarcomas. We generated 14 bone sarcoma PDXs from percutaneous tumor biopsies. We also developed eight bone sarcoma PDXs from surgical resection of primary bone tumors and pulmonary metastases. A multidisciplinary team approach was critical to establish an accurate diagnosis and to provide adequate tumor samples for PDX generation.

Radiologic Analysis of C2 to Predict Safe Placement of Pedicle Screws.

BACKGROUND: Preoperative assessment of C2 pedicle morphology is critical to safe pedicle screw placement. To avoid iatrogenic injury, complex digital templating software has been introduced; however, this technology may not be available in many centers. We report a technique for preoperative assessment of C2 pedicle screw placement safety based upon 2-dimensional sagittal computed tomography (CT) scan images and verify its utility in clinical practice. METHODS: A total of 46 consecutive patients underwent cervical spine CT scans between 2005 and 2011. The C2 pedicle morphology was assessed on sagittal CT imaging by 5 independent reviewers to determine the feasibility and risk associated with pedicle screw placement. Thirty consecutive patients underwent C2 pedicle screw placement and were followed clinically for a minimum of 2 years. The ability to place a screw was noted, and accuracy of screw placement was assessed postoperatively by CT scan. RESULTS: The CT scan analysis demonstrated that 11% (5/46) of patients had sufficient pedicle size bilaterally to allow safe placement of long pedicle screws with a low risk of vertebral artery injury, whereas 15% (7/46) were considered a high risk bilaterally. Screw placement was deemed low risk in 28%, moderate risk in 38%, and high risk in 34%. Excellent intraobserver reliability and good interobserver reliability was observed. Clinically, 18 of 20 (90%) low-risk and 21 of 24 (88%) moderate-risk pedicle screws were placed safely versus 5 of 16 (31%) high-risk pedicle screws (P < .001). CONCLUSIONS: Using the described technique for evaluating the C2 pedicle via sagittal CT scan images allows for safe and reliable pedicle screw placement without relying upon complex digital templating software, which may have limited availability. LEVEL OF EVIDENCE: II. CLINICAL RELEVANCE: This study aids in the surgical decision-making behind the placement of C2 pedicle screws using CT scans without reliance upon complex digital templating software.

Modern Techniques for the Management of Metastatic Spine Disease.

The management of metastatic spine disease has evolved substantially in the past 5 years. Early treatment approaches with more aggressive surgical indications were based on studies that misinterpreted or overemphasized the advantages of the surgical management of metastatic spine disease. However, substantial advantages in radiation therapy, chemotherapy, and biologic agents have led to considerable improvements in patient outcomes and have, in many patients, shifted the paradigm back to nonsurgical or less invasive treatment modalities. Surgeons should be aware of critiques of earlier treatment strategies and associated frameworks for the management of metastatic spine disease. The Medical, Oncologic, Stenosis, and Stability framework was developed to address some of the shortcomings of early metastatic spine disease treatment approaches.

A novel muscle-sparing high thoracotomy for upper thoracic spine resection and reconstruction.

PURPOSE: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions. METHODS: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement. RESULTS: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively. CONCLUSIONS: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components.

Case Report: Angiosarcoma in the Upper Extremity Related to a Nonfunctioning Arteriovenous Fistula.

BACKGROUND: Angiosarcoma is a rare but aggressive malignancy with a high predilection for the head and neck. There have been few case reports of the development of angiosarcoma in a nonfunctional arteriovenous fistula in a hemodialysis patient. METHODS: After institutional review board approval, a retrospective chart analysis is conducted to present the case of a patient who received plastic surgical treatment at our hospital. RESULTS: We present the case of a 44-year-old male who presented with ischemic changes and paresthesias of the upper extremity associated with the development of angiosarcoma in an arteriovenous fistula. CONCLUSIONS: Angiosarcoma remains a rare but important diagnosis to include in the differential diagnosis for upper extremity pain and paresthesias in chronic renal failure and nonfunctioning arteriovenous fistula.

Prolonged bed rest as adjuvant therapy after complex reconstructive spine surgery.

BACKGROUND: The benefits of postoperative mobilization include decreased incidence of pulmonary complications, pressure ulcers, and progression of deep vein thrombosis. However, the complexity of certain spinal reconstructions and the patient's physiologic condition may preclude the possibility of early mobilization. Prolonged bed rest after spine surgery is controversial. QUESTIONS/PURPOSES: We evaluated the efficacy of prolonged bed rest after complex spine surgery to determine (1) patient characteristics that led to prescribing bed rest, (2) clinical and radiographic outcomes, (3) complications, and (4) estimated direct costs. METHODS: We retrospectively reviewed all 11 patients (median age, 50 years) who underwent complex spine surgery followed by prolonged bed rest between 2005 and 2010. All patients were deemed at high risk for developing pseudarthrosis or instrumentation failure without postoperative bed rest. One patient died of complications related to pulmonary tuberculosis at 4 months. The patients averaged 3 months of bed rest. Minimum followup was 24 months (median, 30 months; range, 4-52 months). RESULTS: All patients had (1) tenuous or limited fixation after correction of severe deformity, (2) previously failed spine reconstruction after early mobilization, or (3) limited treatment options if failure occurred again. No patient experienced pseudarthrosis, failure of instrumentation, thromboembolic disease, pressure ulcers, or pneumonia. One patient had a delayed union and one developed late urosepsis. The median cost of skilled nursing facilities during the period of bed rest was $16,702, while the median cost of home health nursing was $5712. CONCLUSIONS: For patients with contraindications to early postoperative mobilization, prolonged bed rest may be useful to minimize the risk of complications that can occur with mobilization. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up.

STUDY DESIGN: Retrospective case series of five consecutive patients. OBJECTIVE: To determine the oncological outcomes and morbidity rates after en bloc excisions of cervical chordomas. SUMMARY OF BACKGROUND DATA: Studies have demonstrated that en bloc surgical excision of chordoma with negative margins results in improved local disease control and survival compared with intralesional resections. Chordomas arising from the cervical spine are rare and they present unique challenges for en bloc tumor excision. We present a series of five consecutive cases of cervical chordoma managed with en bloc tumor excision, which represents one of the largest surgical experiences of cervical chordomas reported to date. METHODS: A retrospective review of our institutional spine tumor database identified five consecutive patients who underwent en bloc tumor excision for cervical spine chordoma from 2000 to 2007. We analyze their surgical margins, perioperative complications, tumor recurrence rate, and survival. RESULTS: Our review demonstrated that dysphagia and cervicalgia were the most common presenting symptoms for cervical chordoma. The mean age of diagnosis in this cohort was 52.4 years and our mean follow-up is 54.7 months. All five patients required multistage procedures to achieve en bloc tumor excision. Independent analysis of the surgical margins by the pathologists revealed that marginal en bloc excisions were achieved in all five patients. Our 30-day perioperative complication was significant for one case of transient radiculopathy with paresis and one wound infection. Other long-term complications included three cases with pseudoarthrosis with instrumentation failures requiring surgical revisions. There were no neurological or cerebrovascular complications. The mean disease-free survival after en bloc spondylectomy for cervical chordoma was 84.2 months in this cohort. CONCLUSION: En bloc excision of chordoma, whether wide or marginal, is the most ideal for treatment to prolong disease-free survival. En bloc excisions of chordomas in the cervical spine are technically complex procedures but can be performed with acceptable safety and perioperative morbidity.