The effect of early mobilisation (< 14 days) on pathophysiological and functional outcomes in animals with induced spinal cord injury: a systematic review with meta-analysis.

INTRODUCTION: The optimum time to mobilise (standing, walking) following spinal cord injury (SCI) is unknown but may have implications for patient outcomes. There are no high-quality experimental studies that examine this issue, with a paucity of guidance for clinicians. Pre-clinical studies lead research in this field and can contribute to knowledge and support future clinical practice. OBJECTIVE: to evaluate the effect of early compared to no mobilisation on pathophysiological and functional outcomes in animals with induced SCI. METHODS: A systematic review with meta-analysis was conducted by searching pre-clinical literature in MEDLINE (PubMed), Embase (Ovid), Web of Science, OpenGrey, and EThOS (June 2023). Studies were included of any research method giving numerical results comparing pathophysiological and functional outcomes in rats and mice mobilised within 14-days of induced SCI to those that did not mobilise. Data were synthesised using random-effects meta-analyses. The quality of the evidence was assessed using the CAMARADES checklist. The certainty of findings was reported using the GRADE approach. This study is registered on PROSPERO (CRD42023437494). RESULTS: Seventeen studies met the inclusion criteria. Outcomes found that Brain Derived Neurotrophic Factor levels were greater in those that initiated mobilisation within 14-days of SCI compared to the groups that did not. Mobilisation initiated within 14-days of SCI was also associated with statistically significant functional gains: (Basso, Beattie and Bresnahan locomotor rating score (BBB) = 2.13(0-21), CI 1.43, 2.84, Ladder Rung Walking Task = - 12.38(0-100), CI 20.01, - 4.76). Meta-analysis identified the greatest functional gains when mobilisation was initiated within 3 days of SCI (BBB = 3.00, CI 2.31-3.69, p < 0.001), or when delivered at low intensity (BBB = 2.88, CI 2.03-3.70, p < 0.001). Confidence in the findings from this review was low to moderate due to the risk of bias and mixed methodological quality. CONCLUSION: Mobilisation instigated within 14-days of injury, may be an effective way of improving functional outcomes in animal models following SCI, with delays potentially detrimental to recovery. Outcomes from this study support further research in this field to guide future clinical practice.

Restoration of the sagittal profile according to the Roussouly classification reduces mechanical complications and revision surgery in older patients undergoing surgery for adult spinal deformity (ASD).

PURPOSE: The mechanical complications related to ASD remain a concern due to their morbidity and associated revision surgery. Restoration of each patient's Roussouly profile may reduce these. Our aim was to examine if the restoration of the Roussouly profile reduced these complications and revision rates in older patients operated for degenerative ASD. METHODS: Retrospective analysis of a single-centre, 2-year minimum follow-up patient database. All patients undergoing corrective surgery (≥ 4 levels) for ASD were included with analysis of demographic data, operative records, restoration of Roussouly sagittal profile, mechanical complications and revision rates. Univariate and multivariate analysis was conducted. RESULTS: Fifty-two patients were included (mean age was 72.3 years, average follow-up 56.3 months). Twenty-six patients had a "restored" profile (50%) and 26 an "unrestored" profile (50%). The incidence of mechanical complications was 7 (27%) and 23 (88%) for the restored and unrestored groups, respectively (p < 0.001). Revision rates were 4 (15.4%) and 18 (69.2%), respectively (p < 0.000), in the restored and unrestored profiles. Univariate analysis determined that profile restoration and BMI were associated with mechanical complications and revision surgery, whilst only the profile restoration status maintained its statistical power in multivariate analysis (p = 0.002 and p = 0.002, respectively). Age was not a significant factor in univariate analysis. The relative risk for mechanical failure and revision surgery was 5.6 times (CI 1.929-16.39) and 3.08 times (CI 1.642-5.734) greater if the profile was not restored. CONCLUSIONS: Achieving each patient's ideal Roussouly profile is associated with a reduced incidence of mechanical complications and revision rates in the older population after surgery for degenerative ASD.

Cost-effectiveness of surgery for degenerative cervical myelopathy in the United Kingdom.

PURPOSE: Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord dysfunction worldwide, for which surgery is the mainstay of treatment. At present, there is limited literature on the costs associated with the surgical management of DCM, and none from the United Kingdom (UK). This study aimed to evaluate the cost-effectiveness of DCM surgery within the National Health Service, UK. MATERIALS AND METHODS: Incidence of DCM was identified from the Hospital Episode Statistics (HES) database for a single year using five ICD-10 diagnostic codes to represent DCM. Health Resource Group (HRG) data was used to estimate the mean incremental surgery (treatment) costs compared to non-surgical care, and the incremental effect (quality adjusted life year (QALY) gain) was based on data from a previous study. A cost per QALY value of <£30,000/QALY (GBP) was considered acceptable and cost-effective, as per the National Institute for Health and Clinical Excellence (NICE) guidance. A sensitivity analysis was undertaken (±5%, ±10% and ±20%) to account for variance in both the cost of admission and QALY gain. RESULTS: The total number of admissions for DCM in 2018 was 4,218. Mean age was 62 years, with 54% of admissions being of working age (18-65 years). The overall estimated cost of admissions for DCM was £38,871,534 for the year. The mean incremental (per patient) cost of surgical management of DCM was estimated to be £9,216 (ranged £2,358 to £9,304), with a QALY gain of 0.64, giving an estimated cost per QALY value of £14,399/QALY. Varying the QALY gain by ±20%, resulted in cost/QALY figures between £12,000 (+20%) and £17,999 (-20%). CONCLUSIONS: Surgery is estimated to be a cost-effective treatment of DCM amongst the UK population.

Complications after early versus late mobilization after an incidental durotomy: a systematic review and meta-analysis.

BACKGROUND: An incidental durotomy (IDT) is a frequent complication of spinal surgery. The conventional management involving a period of flat bed rest is highly debatable. Indeed, there are scanty data and no consensus regarding the need or ideal duration of post-operative bed rest following IDT. OBJECTIVE: To systematically evaluate the literature regarding the outcomes of mobilization within 24 h and after 24 h following IDT in open lumbar or thoracic surgery with respect to the length of hospital stay, minor and major complications. METHODS: A systematic review of the literature using PubMed, Embase and Cochrane and dating up until September 2022 was undertaken following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. RESULTS: Out of 532 articles, 6 studies met the inclusion criteria (1 Level-I, 4 level-III and 1 Level-IV evidence) and were analyzed. Overall, 398 patients of mean age 59.9 years were mobilized within 24 h. The average length of stay (LOS) for this group was 5.7 days. Thirty-four patients (8.5%) required reoperation while the rate of minor complications was 25.4%. Additionally, 265 patients of mean age 63 years with IDT were mobilized after 24 h. The average LOS was 7.8 days. Twenty patients (7.54%) required reoperation while the rate of minor complications was 55%. Meta-analysis comparing early to late mobilization, showed a significant reduction in the risk of minor complications and shorter overall LOS due to early mobilization, but no significant difference in major complications and reoperation rates. CONCLUSIONS: Although early mobilization after repaired incidental dural tears in open lumbar and thoracic spinal surgery has a similar major complication/ reoperation rates compared to late mobilization, it significantly decreases the risk of minor complications and length of hospitalization.

Does kyphoplasty affect the global sagittal alignment in patients with osteoporotic vertebral fractures? A systematic review and meta-analysis.

BACKGROUND: Osteoporotic vertebral compression fractures (OVCF) are common in elderly patients and may cause local kyphosis due to the vertebral collapse and wedging. Balloon kyphoplasty (BKP) with polymethyl methacrylate is widely used to relieve back pain and restore the height and kyphosis of the destroyed vertebra Johnell (Osteoporos Int 17(12):1726-33, 2006); Wasnich (Bone 18: 179S-183S, 1996); Finnern (Osteoporos Int 14:429-436, 2003). However, the influence of BKP on global sagittal alignment (GSA) in patients with OVCF remains unclear. OBJECTIVE: To systematically evaluate the relevant literature regarding the influence of BKP on the global spinal sagittal alignment using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spinosacral Angle (SSA). Visual Analogue Score (VAS) was also recorded. METHODS: A systematic review of the English language literature dating up until August 2022, was undertaken utilising the PRISMA guidelines. RESULTS: Of a total of 548 articles, 4 studies met the inclusion criteria (4 level III evidence) and were analyzed. Overall, 201 patients of mean age 73.8 years (69-77) had acute OVCF of one or more vertebra. The male to female ratio was 51:128. The number of fractured vertebrae was 235 (average of 1.17 fractured vertebrae per patient). Their pre-operative radiological parameters on standing x-rays showed a mean PI of 56°, PT 24.1°, LL 44.4°, TK 42.3°, PI-LL 11.7°, SVA 4.9 cm, LL/TK 1 and SSA 114.8°. The average VAS was 7.6 (2.6-10). All the patients underwent BKP and their radiological parameters on standing x-rays post operatively showed a mean PI of 55.3°, PT 23.1°, LL 45.1°, TK 41.4°, PI-LL 10.3°, SVA 4.29 cm, LL/TK 1.07 and SSA 116.8°. Their average VAS post BPK was 2.36 (0-4.8).A statistical analysis comparing the pre/post-operative GSA (111 patients, 3 studies with standard deviations) showed no statistical difference in PT (24.1° vs. 23.5°, P = 0.93), TK (42.3° vs. 42.4°, P = 0.57), PI-LL (14.4° vs.12.4°, P = 0.4), SVA (6.1 cm vs. 5.5 cm, P = 0.19) SSA (114.8° vs. 116.7° P = 0.36). VAS was significantly reduced post BKP (7.1 vs. 2.5 P = 0.004). CONCLUSION: Performing BKP procedures does not significantly affect the global sagittal alignment in patients with osteoporotic vertebral compression fractures. There was however, a significant improvement in pain scores in patients undergoing BKP at 1 or more levels.

Cluneal nerve release: a systematic review.

BACKGROUND: Despite the heterogeneity of chronic lower back pain aetiologies, cluneal nerve entrapment remains underdiagnosed and poorly understood with few studies discussing the efficacy of its surgical release. OBJECTIVE: The current study opts to conduct a systematic review reporting on the efficacy of cluneal nerve surgical decompression in patients with an established diagnosis who fail conservative treatment. We aimed to systematically evaluate the literature regarding the clinical outcomes, recurrence of symptoms and revision rates of surgical intervention. METHODS: A systematic review of the English language literature dating up until May 2022 was undertaken according to the PRISMA guidelines. Isolated case reports were excluded. RESULTS: Of a total of 54 articles, 4 studies met the inclusion criteria (three were level IV evidence and one level III evidence) and were analyzed. Overall, 98 patients of mean age 61 years, (range 17-86) underwent cluneal nerve release with a mean follow-up of 25.5 months (6-58 months). There was significant improvement in symptoms post operatively in the 4 studies. No systemic or local complications were encountered during the surgeries. Four articles reported on revision surgery for recurrent symptoms in 8 patients out of 98 with a rate of 8.2%. Of the reoperated patients, 7/8 had new branches released that were not addressed initially and 1 had neurectomy for an adhered pre-released branch. CONCLUSION: This systematic review demonstrated that cluneal nerve decompression has been performed in a total of 98 patients with significant clinical improvement, zero systemic and local complications and revision rates of 8.2% of the cases.

Vertebral body tethering in adolescent idiopathic scoliosis with more than 2 years of follow-up- systematic review and meta-analysis.

BACKGROUND CONTEXT: Whilst spinal fusion remains the gold standard in the treatment of adolescent idiopathic scoliosis (AIS), anterior vertebral body tethering (AVBT) is gaining momentum with relatively few studies on its efficacy thus far. PURPOSE: To conduct a systematic review reporting on the early results of AVBT for patients undergoing surgery for AIS. We aimed to systematically evaluate the relevant literature pertaining to the efficacy of AVBT with respect to degree of correction of the major curve Cobb angle, complications and revision rates. STUDY DESIGN/SETTING: Systematic review. PATIENT SAMPLE: Of a total of 259 articles, 9 studies met the inclusion criteria and were analysed. Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. OUTCOME MEASURES: Degree of Cobb angle correction, complications and revision rates were used as outcome measures. METHODS: A systematic review of the literature on AVBT was performed for studies published between Jan 1999-March 2021 applying the PRISMA guidelines. Isolated case reports were excluded. RESULTS: Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. There was a significant correction of the main thoracic curve of scoliosis (mean preoperative Cobb angle 48.5°, post-operative Cobb angle at final follow-up of 20.1°, P = 0.01). Overcorrection and mechanical complications were seen in 14.3% and 27.5% of cases, respectively. Pulmonary complications including atelectasis and pleural effusion were seen in 9.7% of patients. Tether revision was performed in 7.85%, and revision to a spinal fusion in 7.88%. CONCLUSION: This systematic review incorporated 9 studies of AVBT and 196 patients with AIS. The complication and revision to spinal fusion rates were 27.5% and 7.88%, respectively. The current literature on AVBT is restricted largely to retrospective studies with non-randomised data. We would recommend a prospective, multi-centre trial of AVBT with strict inclusion criteria and standardised outcome measures.

The influence of osteoporotic vertebral fractures on global sagittal alignment in elderly patients: a systematic review and meta-analysis.

BACKGROUND: Thoracic kyphosis, or loss of lumbar lordosis, is often equated with osteoporosis because vertebral fractures are assumed to be a major causative factor, in addition to degeneration related to age. Despite the few studies aiming to measure the natural change in global sagittal alignment (GSA) that occurs with advancing age, the overall effect of conservatively managed osteoporotic vertebral compression fractures (OVCF) on the GSA in the elderly remains poorly understood. OBJECTIVE: To systematically evaluate the relevant literature regarding the influence of OVCF on the GSA compared to patients of similar age without fractures using the following radiological parameters: Pelvic Incidence (PI), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK), Sagittal Vertical Axis (SVA) and Spino-sacral Angle (SSA). METHODS: A systematic review of the English language literature dating up until October 2022, was undertaken utilizing the PRISMA guidelines. RESULTS: Of a total of 947 articles, 10 studies met the inclusion criteria (4 Level II, 4 level III and 2 level IV evidence) and were subsequently analyzed. Overall, 584 patients (8 studies) of mean age 73.7 years (69.3-77.1) had acute OVCF of one or more vertebra that were managed conservatively. The male to female ratio was 82:412. Five studies mentioned the number of fractured vertebrae, with a total of 393 in 269 patients (average of 1.4 fractured vertebrae per patient). Their pre-operative radiological parameters on standing X-rays showed a mean PI of 54.8°, PT 24°, LL 40.8°, TK 36.5°, PI-LL 14°, SVA 4.8 cm, and SSA 115°. In addition, 437 patients were used as a control group with osteoporosis without fractured vertebrae, (6 studies) with an average age of 72.4 years (67-77.8) and male to female ratio of 96:210 (5 studies). They all had upright X-rays to assess their global sagittal alignments. Radiological parameters showed an average PI of 54.3°, PT 17.3°, LL 43.4°, TK 31.25°, PI-LL 10.95°, SVA 1.27 cm and SSA 125°. A statistical analysis comparing the OVCF group with the control group (4 studies), showed a significant increase in PT of 5.97° (95%CI 2.63, 9.32; P < 0.0005), a significant increase in TK by 8.28° (95%CI 2.15, 14.4; P < 0.008), an increase in PI-LL by 6.72° (95%CI 3.39, 10.04; P < 0.0001), an increase in SVA by 1.35 cm (95%CI 0.88, 1.83; P < 0.00001), and a decrease in SSA by 10.2° (95%CI 10.3, 23.4; P < 0.00001). CONCLUSION: Osteoporotic vertebral compression fractures managed conservatively appear to be a significant causate factor of global sagittal imbalance.

Hospitalisation for degenerative cervical myelopathy in England: insights from the National Health Service Hospital Episode Statistics 2012 to 2019.

PURPOSE: Degenerative cervical myelopathy (DCM) is the most common cause of adult spinal cord dysfunction worldwide. However, the current incidence of DCM is poorly understood. The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise surgical activity for DCM in England. METHODS: The HES database was interrogated for all cases of DCM between 2012 and 2019. DCM cases were identified from 5 ICD-10 codes. Age-stratified values were collected for 'Finished Consultant Episodes' (FCEs), which correspond to a patient's hospital admission under a lead clinician. Data was analysed to explore current annual activity and longitudinal change. RESULTS: 34,903 FCEs with one or more of the five ICD-10 codes were identified, of which 18,733 (53.6%) were of working age (18-64 years). Mean incidence of DCM was 7.44 per 100,000 (SD ± 0.32). Overall incidence of DCM rose from 6.94 per 100,000 in 2012-2013 to 7.54 per 100,000 in 2018-2019. The highest incidence was seen in 2016-2017 (7.94 per 100,000). The median male number of FCEs per year (2919, IQR: 228) was consistently higher than the median female number of FCEs per year (2216, IQR: 326). The rates of both emergency admissions and planned admissions are rising. CONCLUSIONS: The incidence of hospitalisation for DCM in England is rising. Health care policymakers and providers must recognise the increasing burden of DCM and act to address both early diagnoses and access to treatment in future service provision plans.

Surgical complications and re-operation rates in spinal metastases surgery: a systematic review.

OBJECTIVE: The goal of this study was to review the incidence of complications and unplanned re-operations after surgery for metastatic spinal tumors. BACKGROUND: The spinal column is the most common osseous site for metastatic spread. The goals of the treatment of spinal metastases are largely palliative. The surgical aims include establishing a diagnosis, providing stability, relieving neurological compression and deterioration, decreasing pain and increasing patient independence. Patients with spinal metastases who undergo surgery are considered high risk, with higher morbidity and mortality rates. MATERIALS AND METHODS: A systematic review was undertaken; PubMed and Embase databases were searched between (2010-2020) for relevant publications in English language with the following search items: metastasis OR metastases AND spine AND surgery AND complications OR revision. Using a standard PRISMA template, 2293 articles were identified. Full-text articles of interest were assessed for inclusion criteria of greater than 30 patients. RESULTS: A final number of 19 articles fully met the search criteria. Four were level II evidence, and the remaining were level III/IV. Surgical site infection 6.5% (135/2088) was reported as the main complication following surgery for spinal metastases followed by neurological deterioration 3.3% (53/1595) and instrumentation failure 2.0% (30/1501). Re-operation rate was 8.3% (54/651), with SSI (27.8%) being the most common reason for revision surgery. CONCLUSION: Patients with spinal metastases frequently present with complex therapeutic challenges requiring multidisciplinary team assessment. Surgical site infection (6.5%) was the main reason for a re-operation in patients undergoing surgery for spinal metastases.

The Nottingham radiation protocol for O-arm navigation in paediatric deformity patients: a feasibility study.

BACKGROUND: O-arm assisted pedicle screw placement has been proven to be more accurate than free-hand technique. Radiation exposure remains the primary drawback. We determined the feasibility and safety of a reduced radiation protocol in paediatric patients undergoing scoliosis correction. METHODS: A reduced radiation protocol for a medtronic O-arm navigational system was devised. 3D CT reconstructions of an anthropomorphic pelvic phantom indicated adequate image quality after reduction to 14% of current manufacturer default factors. A feasibility study to test the image quality was undertaken on four patients, one with syndromic and three with idiopathic scoliosis each receiving progressively reducing radiation exposure of 60%, 50%, 40% and 14% of what would have been delivered using the manufacturer default protocol. This represented 32% of the mayo clinic protocol. It was achieved by reducing the x-ray tube current to 10 mA while keeping the tube potential at 90 kVp. RESULTS: A low dose O-arm protocol was able to generate adequate image quality while delivering as little as 14% (for lumbar region reconstructions) of the recommended protocol radiation dose. The total radiation dose delivered with this protocol was approximately 0.8 milliSieverts for a single spin. This effective dose represents < 1/3 of average UK and < 1/6 average US annual radiation exposure. There were no neurological or implant-related complications. CONCLUSIONS: Our low dose O-arm radiation protocol significantly reduces the radiation exposure compared to the manufacturer recommended Mayo clinic protocol providing operational image quality to allow accurate screw placement in spinal deformity.

Clinical outcomes of sacroplasty for metastatic sacral tumours: a systematic review and meta-analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVE: The purpose of this study was to evaluate the clinical outcome and safety of sacroplasty for patients with secondary metastatic lesions to the sacrum. METHODS: Several databases, including the Cochrane library, PubMed and EMBASE, were systematically searched to identify potentially eligible articles in English language. All the above databases were searched until December 2019. The search strategy was based on the combination of the following keywords: sacroplasty AND secondary tumours OR metastasis OR metastases. The reference list of the selected literature was also reviewed and a standard PRISMA template utilised. RESULTS: From a total of 102 articles initially identified, a final seven studies were identified as meeting the inclusion criteria. A total of 107 patients from these studies were included. The follow-up ranged from immediate post-operatively to 30.5 months. The mean preoperative VAS was 8.38 (range 6.9-9.3), which improved significantly to 3.01 (range 1.12-4.7) post-operatively (p < 0.001). The most frequent complication reported was cement leakage, which occurred in 26 patients (25.4%), but without any neurological or other adverse sequelae. CONCLUSIONS: Sacroplasty in the management of secondary sacral tumours is a safe procedure that can achieve a significant reduction in pain, as quantified by VAS scores, and low complication rate.

Impact of pedicle subtraction osteotomy on health-related quality of life (HRQOL) measures in patients undergoing surgery for adult spinal deformity: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND: Three-column osteotomies (3-CO) have gained popularity in the last decade as part of the armamentarium for the surgical correction of sagittal imbalance in patients with adult spinal deformity (ASD). Three-column osteotomies in the form of pedicle subtraction osteotomy (PSO) may be necessary to achieve adequate correction for severe and rigid spinal deformity. Studies reporting improvement in health-related quality of life (HRQOL) with validated outcome measures after PSO surgery are sparse and currently consist of small series. OBJECTIVE: Evaluate the improvement in HRQOL measures following PSO for adult spinal deformity. METHODS: Two independent reviewers conducted a systematic review of the English literature between period 1996 and 2019 for articles reporting outcome of PSO in patients with ASD according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Inclusion criteria were studies consisting of patient-reported outcome Oswestry Disability Index (ODI) and Scoliosis Research Society 22 or 24 (SRS) outcomes after PSO surgery for adult spine deformity patients (18 years or older) with a minimum follow-up of 1 year. RESULTS: Eight studies with 431 PSOs were included in the meta-analysis. The results showed a statistically significant improvement in ODI in PSO (P < 0.0001), and the mean clinically important difference was achieved with both ODI (50.46 (45.5-55.4) preoperatively to 32.78 (29.7-39) postoperatively) and SRS (2.49 (2.38-2.7) preoperatively to 3.26 (2.8-4.1) postoperatively) scores. CONCLUSION: This meta-analysis did find improvements in the health-related quality of life in patients undergoing PSO surgery for adult spinal deformity.

Surgical approaches to L5 corpectomy: a systematic review.

INTRODUCTION: Surgical approaches to pathologies of the L5 vertebra constitute a significant challenge. Our aim was to review the efficacy and safety of the surgical approaches to L5 corpectomy and reconstruction across the range of presenting pathology. MATERIALS AND METHODS: This systematic review was conducted according to PRISMA guidelines, and databases were searched from 1970 to January 2020. The search inclusion criteria were L5 Corpectomy AND/OR Spondylectomy AND/OR Vertebrectomy. The outcome measures studied were length of surgery, blood loss, fusion or failure of fusion/instrumentation, complications and mortality. RESULTS: Initial 36 articles were identified, and final 6 studies met our inclusion criteria. The mean reported blood loss was 2265 ml (400-4700 ml) and was higher for the two-stage posterior-anterior surgery group than the posterior-only surgery group (mean 3230 mls vs. 1260 mls) but not the operative time. All surgical approaches shared high fusion rates (94%) and relatively low complication rates (11.7%). However, surgical strategies incorporating an anterior approach were notable for vascular complications (4-7%), as well as perioperative mortality (9%) not seen in the posterior-only surgery group. CONCLUSION: Where there is clinical and circumstantial equipoise regarding the choice of surgical approaches for a L5 corpectomy, this review indicates a reported mean blood loss of 2265 ml (400-4700 ml), high fusion rates (94%) and relatively low complication rates (11.7%). It is difficult to make direct comparisons between approaches due to small case series, the variability in primary pathology, clinical intent and surgeon experience.

Can MRI findings predict the outcome of cervical spinal cord Injury? a systematic review.

INTRODUCTION: MRI is the established gold standard for imaging acute spinal cord injury (SCI). Our aim was to identify the prognostic value, in terms of neurological outcome, of extradural and intradural features detected on MRI performed acutely following traumatic cervical SCI. MATERIALS AND METHODS: Several databases were systematically searched to identify potentially eligible articles until December 2019. Using a standard PRISMA template, 2606 articles were initially identified. RESULTS: A final 6 full-text articles met the inclusion criteria and were analyzed. An extradural factor, namely the maximal spinal cord compression, was associated with poor neurological outcome and statistically significant (P = 0.02 and P = 0.001 in 2 out of 3 studies). The intradural factors of length of the cord edema (P = 0.001, P = 0.006, and P < 0.001 in 3 studies), intramedullary hemorrhage (P = 0.002, P < 0.001, P < 0.001, and P = 0.002 in 4 studies), and the length of intramedullary hemorrhage (P = 0.028, P = 0.022 in 2 studies) also significantly correlated with poor neurological recovery at follow-up. CONCLUSION: While early MRI is established as a gold standard imaging of acute spinal trauma, it also serves to provide prognostic value on the neurological recovery. From our systematic review, there is a strong association of the extradural finding of maximal spinal cord compression, intradural MRI findings of length of cord edema, intramedullary hemorrhage, and length of intramedullary hemorrhage with neurological recovery in traumatic cervical spinal cord injuries. LEVEL OF EVIDENCE: III.

How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database.

BACKGROUND: The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database. METHODS: The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed. RESULTS: A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%. CONCLUSION: We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method.

PURPOSE: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.

Health-related quality of life in patients undergoing cervico-thoracic osteotomies for fixed cervico-thoracic kyphosis in patients with ankylosing spondylitis.

PURPOSE: Ankylosing spondylitis (AS) can result in severe cervico-thoracic kyphotic deformity (CTKD). Few studies have addressed the relationship between cervico-thoracic osteotomies in AS and health-related quality of life scores. The aim of this study is to evaluate the impact of cervico-thoracic osteotomy (CTO) on improving quality of life for patients with fixed CTKD. METHODS: A database of all patients who underwent a CTO for CTKD in patients with AS was created. Data entered into the database consisted of patients' demographics and comorbidities, as well as surgical, clinical and radiological data. The outcome measures used in our study were Neck Disability Index (NDI), EuroQol 5D-5L (EQ-5D-5L) and Visual Analogue Scale. We also measured the following radiological parameters: chin-brow to vertical angle (CBVA), C7-Slope, C2-7 angle, Regional Kyphosis Angle, C2-C7 sagittal vertical axis (SVA) and C7-S1 SVA. RESULTS: A total of 13 male patients with AS were included in our study. The mean age was 57.5 years (40-74); and mean follow-up was 37.6 months (12-78). Following the C7-T1 osteotomy (10 Smith Peterson Osteotomies and 3 Pedicle Subtraction Osteotomies), NDI improved from a mean of 65.54 (SD 8.95) to a mean of 22.09 (SD 6.99). The EQ-5D-5L improved from a mean of 0.41 (SD 0.16) to 0.86 (SD 0.088). Pre-operative CBVA was on average 54° (40°-75°) and post-operative was 7° (2°-12°). There were no major complications, 1 superficial infection and 5 minor nerve root irritations. CONCLUSIONS: Cervical osteotomy for the management of fixed flexion deformity of cervical spine in ankylosing spondylitis is a safe procedure and can result in restoration of horizontal gaze and sagittal balance with significant improvement of the patient's health-related quality of life. These slides can be retrieved under Electronic Supplementary Material.

The safe use of long screws in L5/S1 stand-alone anterior interbody fusion for olisthesis cases.

BACKGROUND: Stand-alone anterior interbody fusion (STALIF) with poly-ether-ether-ketone (PEEK) cages could offer a treatment option in olisthesis cases. The fixation of the PEEK-cage at the L5/S1 inferior endplate with long divergent screws however might endanger neural sacral structures, especially the S1 nerve root. If shorter screws are used, the achieved bony purchase might not be sufficient to resist the pull out and shear forces at the lumbosacral junction. The aim of the present investigation was to evaluate the use of long screws in PEEK-cages for olisthesis cases at the L5/S1 segment and its neurological complications. MATERIAL AND METHODS: 11 Patients (6 males) with a mean age of 47(± 15.1) years between 2013-2015 designated for an STALIF at the L5/S1 level were consecutively included in the present study. All patients had a Grade 1 or 2 slippage according to Meyerding. PEEK cages (SynFix-LR®, Depuy Synthes) were implanted with 30mm screws at the baseplate of L5/S1 in all patients. Perioperative and postoperative long-term complications were evaluated. Furthermore, radiological follow-up was performed (CT-scan at 6 months, X-ray at 6, 12 and 24 months). RESULTS: 6 patients suffered from an isthmic, 1 from a degenerative olisthesis. 4 patients with iatrogenic spondylolisthesis were included. Pre-operative radiculopathy was noted in 10 patients. 9 patients with pre-operative radiculopathy showed relief of symptoms until the last follow-up after 24 months. Fusion was achieved in all patients after 6 months. No screw-displacement, breakage or violation of the neural foramen was noted. Furthermore, no implant failure or pull-out fractures were seen. CONCLUSION: In this investigation, no complication due to the use of long divergent locking screws was noted. In addition, the majority of patients showed permanent relief of radiculopathy symptoms at the 2 years follow-up. This study demonstrates the safe usage of long divergent locking screws in the baseplate of L5/S1 in anterior interbody fusion at the L5/S1 level.