Bisphosphonate-loaded bone cement: Background, clinical indications and future perspectives.

Bisphosphonates represent an established treatment against bone resorption and osseous loss. Local application could help increase bone mineral density while minimizing their systemic use side-effects. Bone cement, used on a large scale in orthopedic surgery and a historically successful drug carrier, could represent an effective scaffold. The aim of this review was to investigate the alterations produced on the cement's structure and properties by this mixture, as well as its antiosteoporotic and antitumor effect. After a thorough research of articles, title screening and duplicate removal we retained 51 papers. Two independent authors performed abstract and full-text reading, finally leaving 35 articles included in this review. In the current literature, acrylic and calcium phosphate bone cement have been used as carriers. A combination with nitrogen-containing bisphosphonates, e.g., zoledronic acid, provokes modifications in terms of setting time prolongation and mechanical strength decline within acceptable levels, on the condition that the drug's quantity stays beneath a certain plateau. Bisphosphonates in bone cement seem to have a powerful anti-osteoclastic and osteogenic local impact as well as a direct cytotoxic effect against several neoplastic lesions. Further investigation on the subject is required, with specifically designed studies focusing on this method's advantages and potential clinical applications.

Surgical timing in traumatic spinal cord injury: current practice and obstacles to early surgery in Latin America.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate current practice of Latin American spine surgeons regarding surgical timing in patients with traumatic spinal cord injury (tSCI) and to identify potential barriers for early surgery. SETTING: Web-based. METHODS: A web-based questionnaire was sent to members of AOSpine Latin America. Questions involved demographic features, familiarity with management of tSCI, and timing of surgery in various tSCI scenarios. The participants were also asked if they would like to operate earlier on patients with tSCI, indicating potential obstacles to early surgery. RESULTS: A total of 307 surgeons answered the questionnaire. Early surgery (<24 h) is performed by 66.8% for ASIA A, 76.9% for ASIA B, and 76.9% for ASIA C/D injuries. For traumatic cauda equina syndrome (tCES), 85.2% performed surgery within 24 h. For traumatic central cord syndrome (tCCS) without osteoligamentous instability, only 31.5% performed surgery within 24 h and 41.2% follow-up on these patients, indicating surgery if no symptom improvement. Early surgery was performed always or in most cases by 50.4% and 41.8% of surgeons for incomplete and complete tSCI, respectively. The majority (85.4%) would like to operate earlier on patients with tSCI than they actually do. The most frequently perceived barriers to early surgery were difficulty of access to surgical implants (70.9%) and delay in patient transport to reference hospital for surgery (57.8%). CONCLUSION: Latin American spine surgeons tend to operate earlier on patients with tCES and incomplete tSCI, then on those with complete tSCI and tCCS. The most reported obstacles for early surgery involved healthcare resources.

Mechanical Complications in Adult Spinal Deformity Surgery: Can Spinal Alignment Explain Everything?

STUDY DESIGN: Cohort study. OBJECTIVE: Our goal was to verify the validity of the global alignment and proportion (GAP) score, SRS-Schwab, and Roussouly theoretical apex of lordosis in predicting mechanical complications in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Achieving adequate sagittal alignment is critical to obtain favorable outcomes in ASD surgery. It has been proposed that mechanical complications are largely secondary to postoperative spinal alignment. METHODS: Retrospective review of consecutive primary ASD cases that underwent deformity correction in the same institution over a 5-year period. Association between the 6-week postoperative spinal alignment classification and occurrence of mechanical complications on the last follow-up was assessed using logistic regressions. The discriminant capacity was assessed using the receiver operating characteristic (ROC) curve analysis. RESULTS: 58.3% (N = 49/84) of patients presented with mechanical complications and 32.1% (N = 27/84) underwent revision surgery. GAP score did not show discriminant ability to predict complications (AUC = 0.53, 95% confidence interval [CI] = 0.40-0.66, P = 0.58). Conversely, the SRS-Schwab sagittal modifier score demonstrated a statistically significant (although modest) predictive value for mechanical complications (AUC = 0.67, 95% CI = 0.54-0.79, P = 0.008). There was a significant association between pelvic tilt (PT) (P = 0.03) and sagittal vertical axis (SVA) (P = 0.01) at 6 weeks postoperatively and the occurrence of later mechanical complications. There was no significant association between matched Roussouly theoretical apex of lordosis and final outcome (P = 0.47). CONCLUSION: The results point to the complexity of mechanical failure and the high likelihood that causative factors are multifactorial and not limited to alignment measures. GAP score should be used with caution as it may not explain or predict mechanical failure based on alignment in all populations as originally expected. Future studies should focus on etiology, surgical technique, and patient factors in order to generate a more universal score that can be applied to all populations.Level of Evidence: 4.

Publication rate of abstracts presented at the annual meetings of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves.

OBJECTIVE: The objective of this study was to determine the publication rate of abstracts presented at the annual meetings of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves (Spine Summit). METHODS: The authors used a search algorithm in PubMed to determine the publication rate of abstracts presented at the Spine Summit from 2007 to 2012. The variables assessed were presentation modality, topic, meeting year, publication year, destiny journal and its 5-year impact factor (IF), country, and citation count (retrieved from the Scopus database). RESULTS: One thousand four hundred thirty-six abstracts were analyzed; 502 were oral presentations and 934 were digital poster presentations. The publication rate was 53.97% (775/1436). The mean time from presentation to publication was 1.35 ± 1.97 years (95% CI 1.21-1.49 years). The mean citation count of published articles was 40.55 ± 55.21 (95% CI 36.66-44.44). Oral presentations had a higher publication rate (71.51%, 359/502) than digital posters (44.54%, 416/934; OR 3.13, 95% CI 2.48-3.95, p < 0.001). Oral presentations had a higher number of citations (55.51 ± 69.00, 95% CI 48.35-62.67) than digital posters (27.64 ± 34.88, 95% CI 24.28-31.00, p < 0.001). The mean IF of published articles was 3.48 ± 2.91 (95% CI 3.27-3.70). JNS: Spine (191/775, 24.64%), Spine (103/775, 13.29%), and Neurosurgery (56/775, 7.23%) had the greatest number of published articles. The US represented the highest number of published articles (616/775, 79.48%). CONCLUSIONS: The publication rate of the Spine Summit is among the highest compared to other spine meetings. Many of the abstracts initially presented at the meeting are further published in high-IF journals and had a high citation count. Therefore, the Spine Summit maintains its high standards of scientific papers, which reflects the high quality of the research performed in the spine surgery field in North America.

Adolescent idiopathic scoliosis: evaluating perioperative back pain through a simultaneous morphological and biomechanical approach.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) has been associated with diminished postural stability and a greater prevalence of back pain. Currently, the literature is lacking information on the effect of spinal fusion on both postural stability and its association with back pain. Our objectives were to evaluate the postsurgical effect of spinal morphological changes on static standing balance and assess the influence of these alterations on reported pain throughout the perioperative period. METHODS: Twenty consecutive AIS patients schedule to undergo spinal fusion surgery were recruited and followed prospectively at the Shriners Hospitals for Children-Canada. Data was collected at the preoperative, 6 weeks and 6 months postoperative visits. Spinal morphology data was collected through 3D reconstructed simultaneous standing biplanar radiographs using the SterEOS software. Postural balance was assessed through Moticon© sensor insoles and analyzed through their software. The data was simultaneously collected as part of the Global Biomechanical and morphological Assessment. Pain was evaluated through self-reported questionnaires. RESULTS: Morphological curve parameters were significantly reduced after surgery. Balance parameters did not change significantly throughout the perioperative period with the exception of the Center of Pressure of the left foot medial/lateral transient shift (P = 0.017) at 6 weeks. Of note, preoperative balance parameters were associated with the degree of right thoracic Cobb angles (P = 0.029 R = 0.528). Pain scores significantly improved 6 weeks and 6 months after the surgery. Pain intensity diminished in the thoracic and lumbar spine but worsen in the neck region at the 6 weeks and 6 months postoperative time points (P = 0.044). Greater residual Cobb angle difference between Mid thoracic and Thoracolumbar/Lumbar curves was associated with greater pain severity at 6 weeks postop (P < 0.005). In addition, greater residual thoracic deformity was associated with significant pain severity 6 months after surgery (P < 0.05). CONCLUSIONS: Improved spinal morphology of postsurgical AIS patients has no significant impact on their static standing balance. Suggesting that other factors apart from the spinal morphology may contribute to AIS patients' balance during stance. Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain.

Pedicle Screw Instrumentation in Scoliosis Surgery: On Site Simulation Data on Accuracy and Efficiency With Different Techniques.

STUDY DESIGN: Prospective experimental study with on-site simulation. OBJECTIVE: To compare the accuracy and efficiency of different techniques for pedicle screw instrumentation (PSI). SUMMARY OF BACKGROUND DATA: Improving the safety and efficiency of PSI is a critical step to reduce the complication rates and the cost of scoliosis surgery. Innovative operative techniques for PSI have shown to safely improve efficiency, thereby reducing cost. Surgical simulation is a valuable tool to study different operative techniques. METHODS: Five spine fellows instrumented 20 simulation models of a scoliotic spine with 10 pedicle screws per model. Four techniques were studied, including the conventional pedicle probe and the innovative sequential drilling technique, with or without computed tomography (CT)-based navigation. Our primary outcome measures were efficiency and accuracy of PSI. We analyzed the data with bivariate analyses using the Chi-square test for categorical variables and the Student t test or ANalysis Of VAriance with Bonferroni post-hoc tests for continuous variables. RESULTS: The drilling techniques (free hand and navigated) were more efficient as compared with the pedicle probe techniques (P < 0.01). The navigated techniques resulted in better accuracy as compared with the free hand techniques (P = 0.036). Most pedicle breaches were medial (n = 32/52). The concave apical pedicle (T4 right side) had the highest incidence of breaches. There was no significant difference in efficiency comparing the free hand and the navigated pedicle probe techniques (P = 0.261) or comparing the free hand drilling and the navigated drilling techniques (P = 1.00). CONCLUSION: On site surgical simulation is a promising concept for teaching advanced procedural skills. Our findings suggest that navigation improves the accuracy of PSI while sequential drilling safely improves efficiency. Combining navigation with sequential drilling can significantly improve the accuracy and the efficiency of PSI in scoliosis surgery, as previously suggested with our published clinical data. LEVEL OF EVIDENCE: 4.

Assessing publication rate of abstracts presented in spine conferences as a quality benchmark: the example of the Canadian Spine Society Annual Meetings.

INTRODUCTION: Publication rate can indirectly assess the quality of research presented in scientific meetings. Considering presentations at orthopedic surgery and neurosurgery meetings, 10.5-66% of abstracts are published in scientific journals. Publication rate of abstracts presented at CSS Meetings is unknown. The objective of this study was to evaluate the publication rate of abstracts presented at the Canadian Spine Society(CSS) Annual Meetings from 2005to2014. METHODS: In October2018, a systematic PubMed search was performed using title and authors of all abstracts presented at CSS Meetings from 2005 to 2014. The following information was retrieved from the articles and abstracts: year, type of presentation, publication in PubMed, time from presentation to final publication, journal and its impact factor(IF). RESULTS: A total of 621 abstracts were presented at CSS meetings from 2005 to 2014. Publication rate in PubMed was 54.8%(N=340/621). Oral presentations were more likely to be published than poster presentations(63.8%vs44.0%; OR=1.45; CI95%=1.20-1.75; P<0.0001). The mean time from presentation to publication was 1.76 years(±1.93). The 340 identified articles were published in 87 different journals. Most common journals were Spine(N=75; 22.1%), The Spine Journal(N=40;11.8%), and Journal of Neurosurgery:Spine(N=28;8.2%). IF ranged from 0.18 to 47.66(mean=3.73±4.68). IF of articles presented orally were higher than those presented as poster(P=0.038). CONCLUSIONS: The CSS scientific meeting maintain along the years a steady high quality research presentations as manifested by its significant publication rate(54.8%) in medical journals with mean IF of 3.73. In comparison with other spine scientific meetings, publication rates of abstracts presented at CSS meeting is amongst the highest.

Acute postoperative opioid consumption trajectories and long-term outcomes in pediatric patients after spine surgery.

Background: The days following surgery are a critical period where the use of opioids predicts long-term outcomes in adults. It is currently unknown as to whether opioid consumption throughout the acute postoperative period is associated with long-term outcomes in pediatric patients. The aims of this study were to characterize opioid consumption trajectories in the acute postoperative period, identify predictors of trajectory membership and determine associations between opioid consumption trajectories and long-term patient outcomes. Materials and methods: Medication use, pain and mental health status were assessed at baseline in adolescents with idiopathic scoliosis who were scheduled for spinal fusion surgery. Cumulative 6-hr opioid consumption was recorded for up to 5 days after spinal surgery. At 6 months after surgery, medication use, pain and functional activity were evaluated. Growth mixture modeling was used to identify opioid trajectories. Results: One hundred and six patients were included in the study. Mean cumulative 6-hr opioid consumption in the acute postoperative period was 13.23±5.20 mg/kg. The model with the best fit contained 5 acute postoperative trajectories and a quadratic term (AIC =6703.26, BIC =6767.19). Two types of patient behaviors were identified: high opioid consumers (trajectories 4 and 5) and low opioid consumers (trajectories 1, 2 and 3). Intraoperative intrathecal morphine dose was a predictor of trajectory membership (p=0.0498). Opioid consumption during the acute postoperative period was not significantly associated with pain, functional activity or pain medication use at 6 months after surgery. Conclusion: In pediatric patients, intraoperative intrathecal morphine dose predicts opioid consumption in the acute postoperative period. Importantly, opioid consumption during this period does not affect long-term outcomes in pediatric patients after a spine surgery.

Pre-education Enhances the Success of Manual Training for Orthopedic Surgery Residents.

INTRODUCTION: Surgical skill training is difficult due to limited resources and the associated risks in the clinical setting. There have been many studies that have looked at optimizing resident skill techniques out of the operating room to optimize intraoperative teaching. Specifically, as seen in spine surgery performing a laminectomy with a high-speed drill is difficult and requires many hours of training and guidance before a resident can feel comfortable to adequately complete the laminectomy with minimal risk of adverse effects. OBJECTIVE: The objective of this study is to assess if pre-education of residents prior to using the high-speed drill will significantly increase their comfort level, as well as increase the success of laminectomy. DESIGN, SETTING AND PARTICIPANTS: This was done by a prospective cohort study in evaluating 20 orthopedic surgical residents via the objective structured assessment of technical skills and global rating scale. RESULTS: Results showed that residents who had pre-education were in fact more successful in completing the laminectomy with the high-speed drill. CONCLUSIONS: Pre-education, whether via a didactic or simulator-based model are both beneficial to resident's knowledge and surgical skill attainment however the simulator based model did not deem the group more successful in completing the laminectomy with the high-speed drill. Certain technical skills still require unreplaceable hands-on practice to become proficient.

Necrotizing Fasciitis Involving Spine: Unusual Medical Emergency for Spine Surgeon.

BACKGROUND: Necrotizing fasciitis (NF) is a surgical diagnosis characterized by a rapidly progressive soft tissue infection, widespread tissue necrosis, and associated systemic illness. Friability of the superficial fascia, dishwater-gray exudate, and absence of pus are surgical characteristics of this diagnosis. Due to rapid progression of the infection, early recognition and aggressive surgical debridement are crucial to reduce mortality. Despite being commonly seen by general, plastic, and orthopedic surgeons, NF is an extremely rare spine surgery emergency. Our objective is to report on a case of NF involving the spine and highlight this unusual surgical emergency for the spine surgeon. CASE DESCRIPTION: We present a rare case of a 61-year-old woman who presented to the emergency department in septic shock. She had a 1-week history of increasing back pain before presenting to us. Computed tomography revealed extensive soft tissue emphysema with involvement of the L3 vertebral body and spina canal. She underwent emergency surgical debridement. Despite maximal medical and surgical therapies, the patient died secondary to multisystem organ failure within 36 hours of initial presentation. CONCLUSIONS: To the best of our knowledge, the literature presents only 1 previous case reported involving the spine. Necrotizing fasciitis is an unusual surgical spine surgery emergency. Spine surgeons should be aware of this diagnosis in order to provide timely aggressive surgical debridement.

Safety of Patient-Controlled Analgesia After Surgery in Children And Adolescents: Concerns And Potential Solutions.

Patient-controlled analgesia (PCA) is common practice for acute postoperative pain management. Postoperative PCA use decreases pain intensity and improves patient satisfaction when compared to non-PCA routes of medication administration. Although PCA has several advantages regarding efficacy and safety, adverse events remain a concern. Programming errors and protocols, patient monitoring, and PCA by proxy or with continuous infusion are recurring silent dangers of PCA use in children and adolescents. Innovative considerations need to be emphasized for future improvement of PCA devices for elective surgical patients. With technology within the healthcare setting advancing at a fast pace, smart pump technology is something to look forward to.

Fractures After Removal of Spinal Instrumentation: Revisiting the Stress-Shielding Effect of Instrumentation in Spine Fusion.

BACKGROUND: Many practicing spine surgeons believe that instrumentation can be removed during revision surgery in successful posterolateral or anterior spinal fusions, confirmed by computed tomography and intraoperative exploration. The stress-shielding effect of spinal instrumentation was well described in the late 1980s and 1990s but has not received recent attention. Despite the paucity of recent literature, concepts underlying the biology and biomechanics of the spinal fusion mass remain particularly salient given the increasing incidence of revision spinal fusion surgery. The aim of this study was to highlight a potential complication of instrumentation removal owing to stress shielding of instrumentation on the spinal column and fusion mass. METHODS: A retrospective review was performed, and a small case series was described. RESULTS: In 3 cases, despite apparent solid fusion demonstrated on preoperative computed tomography and confirmed by intraoperative exploration, new fractures developed after removal of instrumentation. In these cases, fracture occurred at the transition zone between the newly rigid instrumented area and previous fusion. This highlights the relative weakness of the fusion and may be explained by the stress-shielding effect of instrumentation within the fusion mass. CONCLUSIONS: Spinal instrumentation revision requires careful consideration, and routine implant removal should not be performed. The presence of a solid fusion on computed tomography and/or at intraoperative exploration may not justify implant removal in these cases. In cases of extension of a fusion, use of a bridging connection to the new implants should be considered. The cases presented demonstrate the consequences of the stress-shielding effect of implants on the spine and fusion mass.

Anatomical and technical factors associated with superior facet joint violation in lumbar fusion.

OBJECTIVE The aim of this study was to evaluate the anatomical and surgical risk factors for screw-related facet joint violation at the superior level in lumbar fusion. METHODS The authors conducted a retrospective review of a consecutive series of posterior lumbar instrumented fusions performed by a single surgeon. Inclusion criteria were primary lumbar fusion of 1 or 2 levels for degenerative disorders. The following variables were analyzed as possible risk factors: surgical technique (percutaneous vs open screw placement), depth of surgical field, degree of anterior slippage of the superior level, pedicle and facet angle, and facet degeneration of the superior level. Postoperative CT scans were evaluated by 2 independent reviewers. Axial, sagittal, and coronal views were reviewed. Pedicle screws were graded as intra-articular if they clearly interposed between the superior and inferior facet joints of the superior level. Multivariate logistic regression analyses were conducted to assess the factors associated with this complication. RESULTS One hundred thirty-one patients were included. Interobserver reliability for facet joint violation assessment was high (κ = 0.789). The incidence of superior facet joint violation was 12.59% per top-level screw (33 of 262 proximal screws). The rate of facet violation was 28.0% in the percutaneous technique group (14 of 50 patients) and 12.3% in the open surgery group (10 of 81 patients) (OR 2.26, 95% CI 1.09-4.21; p = 0.024). In multivariate logistic regression analysis, independent predictors of facet violation were percutaneous screw placement (adjusted OR 3.31, 95% CI 1.42-7.73; p = 0.006), right-side pedicle screw (adjusted OR 3.14, 95% CI 1.29-7.63; p = 0.011), and facet angle > 45° (adjusted OR 10.95, 95% CI 4.64-25.84; p < 0.0001). CONCLUSIONS The incidence of facet joint violation was higher in percutaneous minimally invasive than in open technique for posterior lumbar spine surgery. Also, coronal orientation of the facet joint is a significant risk factor independent of the surgical technique.

Current Status of Worldwide Use of Patient-Reported Outcome Measures (PROMs) in Spine Care.

OBJECTIVES: Patient-reported outcome measures (PROMs) are the most widely accepted means of measuring outcomes after spine procedures. We sought to determine the current status of worldwide use of PROMs in Latin America (LA), Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine the barrier to its full implementation. METHODS: A questionnaire survey was sent by e-mail to members of AOSpine to evaluate their familiarity and use of PROMs instruments and to assess the barriers to their use in spine care practice in LA, EU, AP, NA, and ME. RESULTS: A total of 1634 AOSpine members from LA, EU, AP, NA, and ME answered the electronic questionnaire. The percentage of spine surgeons who were familiar with the generic health-related quality of life questionnaire was 71.7%. In addition, 31.9% of respondents did not use any PROMs routinely. The main barriers to implementing PROMs were lack of time to administer the questionnaires (57%) followed by lack of staff to assist in data collection (55%), and the long time to fill out the questionnaires (46%). The routine use of questionnaires was more frequent in NA and EU and less common in LA and ME (P < 0.001). CONCLUSIONS: We found that 31.9% of spine surgeons do not use the PROMs questionnaire routinely. This appears to occur because of lack of knowledge regarding their importance, absence of reimbursement for this extra work, minimal financial support for clinical research, the cost of implementation, and lack of concern among physicians.

Compressive Myelopathy Due to Ossification of the Ligamentum Flavum: Case Report and Review of the Literature

Ossification of the ligamentum flavum (OLF) is a rare condition in which the ligamentum flavum, due to mechanical, biological and genetic factors, becomes ossified. Due to its nature and anatomic location, OLF produces symptoms characteristic of spinal cord compression. The diagnostic confirmation is based primarily on imaging tests such as computed tomography (CT) and magnetic resonance imaging (MRI). Ossification of the ligamentum flavum most often affects Asian populations, rarely occurring in black people. The authors report a case of a 61-year-old black man with progressive paraparesis due to OLF, and review the literature regarding the pathology's prevalence, pathogenesis, clinical features, diagnosis, treatment and prognosis.

A ossificação do ligamento flavo (OLF) é uma doença rara na qual o ligamento flavo se torna ossificado devido a fatores mecânicos, biológicos e genéticos. Devido à sua natureza e localização anatômica, a OLF produz sintomas característicos de compressão da medula espinhal. A confirmação diagnóstica baseia-se principalmente em exames de imagem, como tomografia computadorizada (TC) e ressonância magnética (RM). A OLF afeta mais comumente populações asiáticas, raramente sendo observada em pacientes negros. Os autores relatam o caso de um homem negro de 61 anos com paraparesia progressiva decorrente de OLF com uma revisão da literatura a respeito da prevalência, patogênese, aspectos clínicos, diagnóstico, tratamento e prognóstico desta patologia.

Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature.

STUDY DESIGN: Systematic review. OBJECTIVE: There is a need for synthesizing data on effectiveness of treatments for patients with adult spinal deformity (ASD) due to its increasing prevalence and health care costs for these patients. The objective of this review was to estimate the effectiveness of surgery versus nonoperative care in patients with ASD. METHODS: A systematic review of articles in published in English using PubMed between 2005 and 2015. Surgical and nonsurgical series that reported baseline and follow-up health-related quality of life measures of patients with ASD with a minimum 2 years of follow-up were selected. Independent extraction of articles by 2 authors using predefined data fields, including risk of bias assessment. RESULTS: Surgery significantly reduces disability, pain, and improves patients' quality of life. The average postoperative improvement in Oswestry Disability Index was -19.1 (±9.0), Numerical Rating Scale back pain -4.14 (±1.38), Numerical Rating Scale leg pain -3.36 (±1.33), Short-Form Health Survey 36-SF36-Physical Component score 11.2 (±5.07), and Short-Form Health Survey 36-Mental Component score 9.93 (±4.96). The complication rate ranged from 9.52% to 81.52% (mean = 39.62%), and the need for revision surgery ranged from 1.72% to 40.0% (mean = 15.71%). The best existing evidence about nonoperative care of ASD is provided from observational studies with very high risk of bias. Quantitative analyses of nonsurgical cohorts did not demonstrate significant changes in quality of life of patients after 2 years of observation. CONCLUSIONS: This data may assist clinicians to counsel patients, as well as to inform health care providers and policymakers about what to expect from the treatment for ASD.

Hypofractionated Stereotactic Radiosurgery and Radiotherapy to Large Resection Cavity of Metastatic Brain Tumors.

OBJECTIVE: To evaluate the efficacy of postoperative fractionated stereotactic radiosurgery (FSRS) and hypofractionated stereotactic radiotherapy (SRT) to large surgical cavities after gross total resection of brain metastases. METHODS: A retrospective analysis of 41 patients who had received tumor-bed FSRS (5 fractions) or SRT (10 fractions) after resection of brain metastasis between 2005 and 2015 was performed. All resection cavities were treated with a frameless linear accelerator-based system. Patients who underwent subtotal resection, single-dose SRS to the resection cavity, or were treated with a fractionation schedule other than 5 or 10 fractions, were excluded. RESULTS: Twenty-six patients were treated with 5 fractions and 15 patients with 10 fractions. The median planning target volume was 19.78 cm3 (12.3-28 cm3) to the 5-fraction group and 29.79 cm3 (26.3-47.6 cm3) to the 10-fraction group (P = 0.020). The 1-year and 2-year local control rates for all patients were 89.4% and 77.1%, respectively, and 89.6% and 78.6% were free from distant intracranial progression, respectively. No difference was observed in local control or freedom from distant intracranial progression between the 5-fraction or 10-fraction groups. The median overall survival was 28.27 months (95% confidence interval, 19.42-37.12) for all patients. No patient developed necrosis at the resection cavity. CONCLUSIONS: Fractionation offers the potential to exploit the different biological responses between neoplastic and normal tissues to ionizing radiation. The use of 5 daily doses of 5-6 Gy or 10 daily doses of 3 Gy is a good strategy to have a reasonable local control and avoid neurotoxicity.

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery.

OBJECTIVE: To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. METHODS: Retrospective analysis of 583 surgically-treated patients. Early "major" complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. RESULTS: Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. CONCLUSIONS: This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery / Escore simples para predizer complicações precoces graves em cirurgia de coluna: o efeito cumulativo da idade e tamanho da cirurgia

ABSTRACT Objective To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. Methods Retrospective analysis of 583 surgically-treated patients. Early “major” complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. Results Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. Conclusions This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

RESUMO Objetivo Analisar os efeitos cumulativos dos fatores de risco associados com complicações precoces graves relacionadas à cirurgia da coluna. Métodos Análise retrospectiva de 583 pacientes tratados cirurgicamente. Complicações graves foram definidas como as que pudessem levar a danos permanentes ou que necessitassem de reinterveção. Um escore foi construído usando modelo de regressão logística. Resultados Noventa e duas complicações precoces graves ocorreram em 76 pacientes (13%). Idade > 60 anos e cirurgia > 3 níveis foram identificadas como fatores de risco independentes na análise multivariada. O escore foi definido como: 0 pontos (nenhum fator de risco), 2 pontos (1 fator) ou 4 pontos (2 fatores). A incidência de complicação grave precoce em cada categoria foi 7% (0 pontos), 15% (2 pontos) e 29% (4 pontos). Conclusões Esse escore balanceado baseado em 2 fatores de risco representa uma ferramenta útil na indicação cirúrgica e para o aconselhamento dos pacientes antes da cirurgia.