Long-term results of Phase II study of high dose photon/proton radiotherapy in the management of spine chordomas, chondrosarcomas, and other sarcomas.

BACKGROUND: Negative surgical margins are uncommon for spine sarcomas; hence, adjuvant radiotherapy (RT) may be recommended but tumor dose may be constrained by spinal cord, nerve, and viscera tolerance. METHODS: Prospective Phase II clinical trial incorporating high dose RT. Eligible patients had primary or locally recurrent thoracic, lumbar, and/or sacral spine/paraspinal chordomas or sarcomas. Treatment included pre- and/or post-operative photon/proton RT ± radical resection. RESULTS: Fifty patients (29 chordoma, 14 chondrosarcoma, 7 other) underwent gross total (n = 25) or subtotal (n = 12) resection or biopsy (n = 13). RT dose was ≤72.0 GyRBE in 25 patients and 76.6-77.4 GyRBE in 25 patients. With 7.3-year median follow-up, the 5 and 8-year actuarial local control (LC) rates were 94% and 85% for primary tumors and 81% and 74% for the entire group. Local recurrence was less common for primary tumors, 4/36 (11%) versus 7/14 (50%) for recurrent tumors, P = 0.002. The 8-year actuarial risk of grade 3-4 late RT morbidity was 13%. No myelopathies were seen. No late neurologic toxicities noted with radiation doses ≤72.0 GyRBE while three sacral neuropathies appeared after doses of 76.6-77.4 GyRBE. CONCLUSIONS: LC with this treatment is high in patients with primary tumors. Late morbidity appears to be acceptable.

Complications of cervical halo-vest orthoses in elderly patients.

Halo-vest orthoses have been associated with complications. Previous reports have suggested increased complications in elderly patients; however, data are limited. This study reviewed 75 patients =/>65 years with cervical spine fractures treated with halo-vest orthoses. Forty-one patients (55%) experienced at least 1 complication. Pin-site problems were the most frequent adverse outcome. Seventeen patients (23%) had significant pulmonary compromise. Pulmonary complications were associated with high morbidity. We found an 8% early mortality rate. Halo-vest orthoses are useful devises. However, adverse events experienced by elderly patients are common and may lead to significant morbidity and mortality.

Modified En Bloc Spondylectomy for Tumors of the Thoracic and Lumbar Spine: Surgical Technique and Outcomes.

BACKGROUND: Total en bloc spondylectomy (TES) for the treatment of spinal tumors decreases local recurrence and improves survival compared with intralesional resection. TES approaches vary in both the number of stages to complete the procedure and instruments with which osteotomies are performed. METHODS: We describe a 2-stage technique that employs the use of threadwire saws. We performed a retrospective review of cases of primary tumors and solitary metastases involving the thoracic or lumbar spine treated with use of our modified technique at our institution between 2010 and 2016, identifying eligible patients by searching for specific phrases in operative reports found in our oncologic database. Clinical notes, operative notes, imaging reports, and pathology reports were reviewed for all patients. RESULTS: Thirty-three patients underwent our modified technique, in which we pass a threadwire saw between the vertebral body and the thecal sac. The most common tumor type was chordoma (64%), and tumors were most commonly located in the lumbar spine (61%). There were no intraoperative injuries to the spinal cord or great vessels. One patient experienced a dural tear secondary to the passage of a saw. Seventeen (52%) of the patients had perioperative complications, with 1 death. Seven (22%) of the patients had complications occurring within 90 days after discharge, and 8 (25%) had complications occurring >90 days after discharge. Instrumentation failure was observed in 8 cases (25%). Negative margins were obtained in 94% of the cases. Local recurrence was observed in 2 cases (6%). The majority of patients had normal motor function at the time of the most recent follow-up. CONCLUSIONS: Our modified en bloc spondylectomy represents an effective technique for the resection of spinal tumors in selected patients, allowing for visualization of vessels anterior to the spine and the avoidance of spinal cord injury. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Quality of life after en bloc resection of tumors in the mobile spine.

BACKGROUND CONTEXT: Little has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity. PURPOSE: The purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL. STUDY DESIGN: This is a retrospective case-control study (Level III). PATIENT SAMPLE: Thirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months). OUTCOME MEASURES: The outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI). METHODS: We performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores. RESULTS: We identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL. CONCLUSIONS: Patients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Utility of Flexion-Extension Radiographs in Lumbar Spondylolisthesis: A Prospective Study.

STUDY DESIGN: Prospective cohort study in consecutive patients. OBJECTIVE: To investigate and compare the use of 2 diagnostic modalities in the evaluation of stability in lumbar spondylolisthesis. SUMMARY OF BACKGROUND DATA: Evaluating potential instability in lumbar spondylolisthesis is significant to its management. Lateral lumbar flexion-extension (FE) radiograph is frequently obtained on the basis of a thought that this forward-backward movement can actually describe hypermobility at the listhetic segment. However, simply comparing standard upright lumbar lateral radiograph (U) with a supine sagittal magnetic resonance image (S) (combined, US), something typically conducted for patients with lumbar spondylolisthesis, may also be used. METHODS: This prospective study included a cohort of 68 consecutive patients with lumbar spondylolisthesis seen in the outpatient clinic of a single hospital. The mobility observed in US was compared with that observed in FE. The ability to identify "instability" using US was compared with that using FE. In addition, the relationships between mobility determined using FE or US and sex, age, height, weight, body mass index, primary symptom (with or without back pain), nature of spondylolisthesis (degenerative or isthmic), listhetic segment, slippage grade, and focal disc height were examined. RESULTS: Overall, the mobility in US was significantly higher than that in FE (7.68 ± 5.34% vs. 4.90 ± 3.82%, t =-3.545, P = 0.001). The ability to identify "instability" on the basis of US was improved compared with that obtained using FE. Female patients demonstrated higher mobility in FE than male patients to a significant degree. Back pain, isthmic spondylolisthesis, and slippage grade also showed some relevance with mobility but without statistical significance. CONCLUSION: US may offer an easily available, alternative diagnostic modality in lumbar spondylolisthesis, with the potential of reducing both radiation exposure and costs. Further studies should focus on its influence in clinical decision making. LEVEL OF EVIDENCE: 2.

High-dose proton-based radiation therapy in the management of spine chordomas: outcomes and clinicopathological prognostic factors.

OBJECT: Spinal chordomas can have high local recurrence rates after surgery with or without conventional dose radiation therapy (RT). Treatment outcomes and prognostic factors after high-dose proton-based RT with or without surgery were assessed. METHODS: The authors conducted a retrospective review of 126 treated patients (127 lesions) categorized according to disease status (primary vs recurrent), resection (en bloc vs intralesional), margin status, and RT timing. RESULTS: Seventy-one sacrococcygeal, 40 lumbar, and 16 thoracic chordomas were analyzed. Mean RT dose was 72.4 GyRBE (relative biological effectiveness). With median follow-up of 41 months, the 5-year overall survival (OS), local control (LC), locoregional control (LRC), and distant control (DC) for the entire cohort were 81%, 62%, 60%, and 77%, respectively. LC for primary chordoma was 68% versus 49% for recurrent lesions (p = 0.058). LC if treated with a component of preoperative RT was 72% versus 54% without this treatment (p = 0.113). Among primary tumors, LC and LRC were higher with preoperative RT, 85% (p = 0.019) and 79% (0.034), respectively, versus 56% and 56% if no preoperative RT was provided. Overall LC was significantly improved with en bloc versus intralesional resection (72% vs 55%, p = 0.016), as was LRC (70% vs 53%, p = 0.035). A trend was noted toward improved LC and LRC for R0/R1 margins and the absence of intralesional procedures. CONCLUSIONS: High-dose proton-based RT in the management of spinal chordomas can be effective treatment. In patients undergoing surgery, those with primary chordomas undergoing preoperative RT, en bloc resection, and postoperative RT boost have the highest rate of local tumor control; among 28 patients with primary chordomas who underwent preoperative RT and en bloc resection, no local recurrences were seen. Intralesional and incomplete resections are associated with higher local failure rates and are to be avoided.

Epithelioid hemangioma of the spine: a case series of six patients and review of the literature.

BACKGROUND CONTEXT: Epithelioid hemangioma (EH) of bone is a benign vascular tumor that can be locally aggressive. It rarely arises in the spine, and the optimum management of EH of the vertebrae is not well delineated. PURPOSE: The report describes our experience treating six patients with EH of the spine in an effort to document the treatment of the rare spinal presentation. STUDY DESIGN: This study is designed as a retrospective cohort study. PATIENT SAMPLE: A continuous series of patients with the diagnosis of EH of the spine who presented at our institution. OUTCOME MEASURES: The clinical and radiographic follow-up of the patient population is documented. METHODS: The Bone Sarcoma Registry at our institution was used to obtain a list of all patients diagnosed with EH of the spine. Medical records, radiographs, and pathology reports were retrospectively reviewed in all cases. Only biopsy-proven cases were included. RESULTS: The six patients included five men and one woman who ranged in age from 20 to 58 years (with an average age of 40 years). The follow-up available for all six patients ranged from 6 to 115 (average 46.8) months. All patients presented with lytic vertebral body lesions. Five patients presented with pain secondary to their tumor, and the tumor in the sixth patient was found incidentally during the workup for a herniated disc. Three patients required surgical management for instability secondary to the destructive nature of their tumors, and two other patients required emergent decompression secondary to spinal cord compression by the tumor. The sixth patient was treated expectantly after biopsy confirmation. Three patients received postoperative radiation therapy as gross tumor remained after surgery. Three patients had gross total resections and did not receive postoperative radiation. Preoperative embolization was used in four patients. One patient continued to have back pain after surgery and radiation and another continued to have ataxia after surgery and radiation. No tumor locally recurred or progressed. CONCLUSIONS: Our data suggest that EH of the spine can be locally aggressive and lead to instability and cord compression. Surgery is required in such instances; however, observation should be considered in patients without instability or cord compression.

Anterior spinal arthrodesis with structural cortical allografts and instrumentation for spine tumor surgery.

STUDY DESIGN: The authors report on anterior vertebral reconstruction following tumor resection with use of fresh-frozen, cortical, long-segment allografts prepared from diaphyseal sections of long bones. A retrospective analysis of clinical outcomes is presented. OBJECTIVE: To analyze the results following the use of cortical allografts in the treatment of spine tumors. SUMMARY OF BACKGROUND DATA: Metastatic disease and primary spinal bone tumors may result in progressive vertebral collapse, instability, deformity, pain, and neurologic deficit. Controversy as to the appropriate type of anterior reconstruction and/or graft material persists. METHODS: From 1995 until 2001, 30 patients with primary spinal bone tumors or metastases to the spine were treated by anterior vertebral reconstruction with fresh-frozen cortical bone allografts. Grafts were used in combination with anterior and posterior instrumentation. RESULTS: The median survival was 14 months. Ninety-three percent of all allografts were radiographically incorporated as early as 6 months after surgery in spite of adjuvant chemotherapy and radiation therapy. Fourteen patients (46%) had intraoperative or postoperative complications. Two patients underwent revision surgery for local recurrence. There were no allograft infections, fractures, or collapse. CONCLUSION: Anterior column reconstruction with structural cortical allografts proved to be a reliable technique in patients with spine tumors. Postoperative complications can often be successfully managed.