More help than harm: surgery for metastatic spinal cord compression is associated with more favorable overall survival within a propensity score analysis.

PURPOSE: Indication for surgical decompression in metastatic spinal cord compression (MSCC) is often based on prognostic scores such as the modified Bauer score (mBs), with favorable prognosis suggestive of surgery and poor prognosis of non-surgical management. This study aimed to clarify if (1) surgery may directly affect overall survival (OS) aside from short-term neurologic outcome, (2) explore whether selected patient subgroups with poor mBs might still benefit from surgery, and (3) gauge putative adverse effects of surgery on short-term oncologic outcomes. METHODS: Single-center propensity score analyses with inverse-probability-of-treatment-weights (IPTW) of OS and short-term neurologic outcomes in MSCC patients treated with or without surgery between 2007 and 2020. RESULTS: Among 398 patients with MSCC, 194 (49%) underwent surgery. During a median follow-up of 5.8 years, 355 patients (89%) died. MBs was the most important predictor for spine surgery (p < 0.0001) and the strongest predictor of favorable OS (p < 0.0001). Surgery was associated with improved OS after accounting for selection bias with the IPTW method (p = 0.021) and emerged as the strongest determinant of short-term neurological improvement (p < 0.0001). Exploratory analyses delineated a subgroup of patients with an mBs of 1 point who still benefited from surgery, and surgery did not result in a higher risk of short-term oncologic disease progression. CONCLUSION: This propensity score analysis corroborates the concept that spine surgery for MSCC associates with more favorable neurological and OS outcomes. Selected patients with poor prognosis might also benefit from surgery, suggesting that even those with low mBs may be considered for this intervention.

Spinal Surgery Site Infection Leading to Implant Loosening Is Influenced by the Number of Prior Operations.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Spinal surgery site infection and chronic implant infection are possible causes for ongoing pain, implant loosening, and failed back surgery syndrome. Evidence of chronic infection was found in 29.1% of revision cases but is also found in a considerable number of degenerative cases without prior surgery. Infection mechanisms and possible clinical correlations are unclear. METHODS: Retrospective analysis of standardized surgery site screening (swab, tissue samples, implant sonication) in 181 cases without clinical evidence of preoperative surgery site infection. RESULTS: Screening results of cases without prior spinal surgery (n = 49, 10.2% positive) were compared to cases with prior spine surgery without implant placement (e.g. micro discectomy) (n = 21, 23.8% positive), revision cases following singular spinal fusion (n = 73, 23.2% positive), and cases with multiple revisions (n = 38, 50.0% positive). Propionibacterium spp. detection rate increased to 80% in positive cases with multiple revisions. Implants in place during revision surgery had a significantly higher infection rate (32.4%) compared to no implant (14.2%, p = 0.007). Positive cases had a significantly higher pain level prior to surgery compared to negative cases (p = 0.019). Laboratory parameters had no predictive value. Logistic regression revealed that previous spinal surgeries (odds ratio [OR] 1.38 per operation, p < 0.001) and male sex (OR 1.15, p = 0.028) were independent predictive factors for infection. CONCLUSIONS: Previous spinal surgery is a risk factor for chronic surgery site infection, leading to chronic pain, implant loosening, and revision. The presence of Propionibacterium spp. was correlated with chronic implant loosening and was more likely with cumulative surgeries.

Risk adapted diagnostics and hospitalization following mild traumatic brain injury.

INTRODUCTION: Traumatic brain injury (TBI) remains a leading cause of hospital admission and mortality, intracranial hemorrhage (ICH) presents a severe complication. Low complication tolerance in developed countries and risk uncertainty, often cause excessive observation, diagnostics and hospitalization, considered unnecessary and expensive. Risk factors predicting ICH, progression and death in patients hospitalized with mild TBI have not been identified yet. METHODS: Mild TBI cases indicated for cranial computer tomography (CT) and hospitalization, according to international guidelines, at our Level I Trauma Center between 2008 and 2018 were retrospectively included. Multivariate logistic regression was performed for ICH, progression and mortality predictors. RESULTS: 1788 mild TBI adults (female: 44.3%; age at trauma: 58.0 ± 22.7), were included. Skull fracture was diagnosed in 13.8%, ICH in 46.9%, ICH progression in 10.6%. In patients < 35 years with mild TBI, chronic alcohol consumption (p = 0.004) and skull fracture (p < 0.001) were significant ICH risk factors, whilst in patients between 35 and 65 years, chronic alcohol consumption (p < 0.001) and skull fracture (p < 0.001) revealed as significant ICH predictors. In patients with mild TBI > 65 years, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p < 0.001) were significant, independent risk factors for ICH, whilst increased age (p = 0.01) was a risk factor for mortality following ICH in mild TBI. Late-onset ICH only occurred in mild TBI cases with at least two of these risk factors: age > 65, anticoagulation, neurocranial fracture. Overall hospitalization could have been reduced by 15.8% via newly identified low-risk cases. CONCLUSIONS: Age, skull fracture and chronic alcohol abuse require vigilant observation. Repeated CT in initially ICH negative cases should only be considered in newly identified high-risk patients. Non-ICH cases aged < 65 years do not gain safety from observation or hospitalization. Recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics.

A novel method of clinical first tarsometatarsal joint hypermobility testing and radiologic verification.

BACKGROUND: First tarsometatarsal joint (TMT-1) hypermobility might cause hallux valgus deformity (HV), and recurrence following surgical correction. Anatomic findings, indicating tibialis anterior tendon (TAT) involvement in TMT­1 stabilization, led to the development of cross-glide test allowing clinical TMT­1 stability testing. Cross-glide test function was evaluated in anatomical specimens and in the clinical setting, compared to simulated weight-bearing computer tomography (CT) analysis. METHODS: Cross-glide test was evaluated in 6 healthy lower leg specimens before and after TAT transection. Clinical testing was performed prospectively in 36 feet (6 controls, 21 HV, 9 recurrent HV); consecutive weight-bearing CT analysis was performed. Results from clinical testing were compared to CT analysis. RESULTS: TMT­1 instability significantly increased in anatomic specimens following TAT transection (p = 0.009). In the clinical setting, all healthy feet were cross-glide test negative, 62% of HV cases and all recurrent HV feet were positive. In the CT analysis- Compared to controls the HV cases revealed significantly increased MT­1 internal rotation (p = 0.003) and decreased dorsal angle (p = 0.002), considered as collapsing forefoot signs; HV recurrent cases revealed similar results. Positive cross-glide tested cases revealed increased MT­1 internal rotation values (p < 0.001) and dorsal angle values (p < 0.001) in CT analysis. Strikingly, cross-glide test positive HV cases revealed significantly increased internal TMT­1 rotation (p = 0.043) in CT analysis, and HV and IMT (intermetatarsal) angle were significantly higher (p = 0.005, p = 0.006). 15 HV recurrence cases, treated with TMT­1 arthrodesis, revealed no recurrence during follow-up. CONCLUSION: Cross-glide test allows reliable clinical TMT­1 instability testing, via TAT tension, and is less laborious than CT analysis. We recommend TMT­1 arthrodesis in cases with instability in clinical testing, to avoid HV recurrence.

Langerhans-cell histiocytosis of the cervical spine in an adult patient: Case report and review of the literature.

Langerhans-cell histiocytosis (LCH) is a rare, benign bone tumor, usually occurring in children and younger adults under 20 years old. Only a few cases of solitary bone lesions of the adult spine are reported in literature, therapeutic guidelines or treatment regimens for lesions of the adult spine are not established yet to our knowledge.

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3).

BACKGROUND: A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus. METHODS: After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending). RESULTS: Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws. CONCLUSION: Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.