Dynesys® dynamic stabilization outcomes in degenerative spine surgery.

Dynesys® is a dynamic device used for posterior stabilization of the lumbar spine. The objective of this study was to analyze the clinical and radiological outcomes at a 2-year minimum follow-up. In this retrospective study, patients operated between 2009 and 2016 with Dynesys® stabilization were included. 5 different etiologies were included: disc herniation, lumbar stenosis, revision for adjacent seg- ment disease (ASD), spondylolisthesis, and scoliosis. Clinical and radiological evaluations were performed. Postoperative complications and revisions were recorded. 136 patients were included: 34 for lumbar spinal stenosis, 19 for disc herniation, 29 degenerative spon- dylolisthesis, 41 revisions for ASD, and 13 scoliosis. Mean age was 64.8. Average clinical follow-up was 46 months. Postoperative clinical results showed a mean lumbar VAS of 3.07, a mean radicular VAS of 3.01 and an ODI score of 31.8%. The ASD rate was 16.2%, and overall revision rate was 11.8%. 2 cases (1.5%) of screw loosening were identified. Clinical outcomes, ASD rate and revision rate were more favorable in the spondylolisthesis and disc herniation groups. This study has one of the largest Dynesys® cohort in literature. Spinal dynamic stabilization by Dynesys® presents good long-term clinical and radiological out- comes with a lower rate of complications than pre- viously published cohorts and lumbar fusions. Best indications seem to be degenerative spondylolisthesis.

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.

Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort.

Introduction Metastatic spinal cancer is a common condition that may lead to spinal instability, pain and paralysis. In the 1980s, surgery was discouraged because results showed worse neurological outcomes and pain compared with radiotherapy alone. However, with the advent of modern imaging and spinal stabilisation techniques, the role of surgery has regained centre stage, though few studies have assessed quality of life and functional outcomes after surgery. Objective We investigated whether surgery provides sustained improvement in quality of life and pain relief for patients with symptomatic spinal metastases by analysing the largest reported surgical series of patients with epidural spinal metastases. Methods A prospective cohort study of 922 consecutive patients with spinal metastases who underwent surgery, from the Global Spine Tumour Study Group database. Pre- and post-operative EQ-5D quality of life, visual analogue pain score, Karnofsky physical functioning score, complication rates and survival were recorded. Results Quality of life (EQ-5D), VAS pain score and Karnofsky physical functioning score improved rapidly after surgery and these improvements were sustained in those patients who survived up to 2 years after surgery. In specialised spine centres, the technical intra-operative complication rate of surgery was low, however almost a quarter of patients experienced post-operative systemic adverse events. Conclusion Surgical treatment for spinal metastases produces rapid pain relief, maintains ambulation and improves good quality of life. However, as a group, patients with cancer are vulnerable to post-operative systemic complications, hence the importance of appropriate patient selection.

Risk factors for spinal cord lesions in dystonic cerebral palsy and generalised dystonia.

BACKGROUND: Cervical myelopathy (CM) in patients with cerebral palsy (CP) is underdiagnosed as symptoms of spinal cord lesions, being similar to those due to dystonia, may be overlooked or identified late. The aim of this study is to identify the risk factors and clinical characteristics of CM in patients with generalised dystonia, including dystonic CP. METHODS: The authors conducted a case-control study to identify early clinical signs of CM in consecutive patients with generalised dystonia. The authors compared the clinical characteristics and symptoms of those who developed CM (cases) and those who did not (controls). The same clinical information on possible neurological manifestations of CM was collected for cases and controls at the date of the last visit. RESULTS: Out of 54 patients, 17 (31%) developed symptomatic CM during the study period. In all cases, CM occurred after the age of 36 years. 81% of cases and 35% of controls had a Burke-Fahn-Marsden movement subscore for the neck >4. Age (OR per 10 years=2.3, 95% CI 1.4 to 4.2, p=0.006) and severity of neck dystonia (OR=7.7, 95% CI 1.7 to 49.6, p=0.005) were the main risk factors of CM. Gait disorders and falls, wasting of hand muscles and bladder disorders were the best clinical clues of CM. CONCLUSIONS: As severity of cervical dystonia and age are the major risk factors for spinal cord lesions, dystonic patients, including patients with dystonic CP, should be screened for CM from the third decade of life onwards. Early recognition of CM is crucial for functional prognosis and impact on autonomy.

Sexual activity resumption after total hip arthroplasty: A satisfaction survey in 101 patients.

BACKGROUND: We are not aware of studies conducted in France to assess information provided by surgeons about the impact of total hip arthroplasty (THA) on sexual activity or sexual activity resumption after THA. The objectives of this study in a cohort of patients seen after THA were to evaluate: (1) the time to sexual activity resumption, (2) whether sexual activity resumption was discussed with the surgeon and whether the patients wanted information on this point, and (3) the modalities and experience of sexual activity resumption according to demographic features. HYPOTHESIS: Age and sex influence the timing and modalities of sexual activity resumption after THA. METHODS: We conducted a single-centre prospective cohort study in consecutive patients who received follow-up for 6months after THA. Each patient completed an anonymised questionnaire on preoperative sexual activity, modalities of postoperative sexual activity resumption, information delivered by the surgeon, and expectations regarding the delivered information. The patients also specified their age and sex on the questionnaire. RESULTS: Of 101 included patients, 49 were still sexually active before surgery. Of these 49 patients, 35 (71.4%) reported no difference in the frequency of sexual activity before and after THA. Only 4 (8.2%) patients did not resume sexual activity during follow-up. Older age was associated with a lower demand for information [odds ratio, 0.95; 95% confidence interval: 0.91-0.99 (p=0.01)]. Compared to the females, the males more often recovered similar sexual activity to that before surgery regarding frequency [18/20 vs. 17/29 (p=0.02)] and quality of sexual positions [15/20 vs. 9/29 (p=0.003)]. Males resumed sexual activity on average during the first 3weeks [10/20 (p=0.02)], compared to after 6weeks for most females [13/29 (p=0.03)]. Age was not associated with the time to sexual activity resumption [ρ=0.0868; 95% confidence interval: -0.205 to 0.365 (p=0.56)]. DISCUSSION: Among patients who were sexually active before surgery, 71.4% reported having resumed the same frequency of sexual activity 6months after surgery. The main difficulty in both males and females was fear of prosthetic hip dislocation, which was related in part to insufficient preoperative information. Males resumed sexual activity earlier than did females. In patients who were sexually active before surgery, age was not associated with the resumption of sexual activity after surgery. LEVEL OF EVIDENCE: IV, prospective study with no control group.

Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations.

INTRODUCTION: Peripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival. HYPOTHESIS: Global function is improved by surgery, with acceptable survival. MATERIAL AND METHOD: Between 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years' follow-up. RESULTS: The most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8-17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2-8.9), prostate 11.1 months (95% CI: 5.3-43.6), kidney 12.9 months (95% CI: 8.4-22.6), breast 26.5 months (95% CI: 19.0-34.0), and thyroid 49.0 months (95% CI: 12.2-NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59-3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40-2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13-1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21-26.71 (p<0.001)). CONCLUSION: Although function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates. LEVEL OF EVIDENCE: IV; retrospective observational.

Influence of preoperative biological parameters on postoperative complications and survival in spinal bone metastasis. A multicenter prospective study.

INTRODUCTION: Onset of spinal bone metastasis is a turning point in the progression of tumoral disease; although incidence is increasing, management is not standardized. Various prognostic scores are available, but advances in medical and surgical treatment have made them less well adapted, and sometimes discordant for a given patient. It would therefore be useful to develop new prognostic instruments. The aim of the present study was to identify biologic risk factors for onset of postoperative complications and death following spinal bone metastasis surgery. MATERIAL AND METHODS: A prospective multicenter study included all patients operated on for spinal bone metastasis between November 2015 and May 2017. The main epidemiologic data and biologic data (CRP, albuminemia, calcemia) were collected preoperatively. Surgical strategy, death and/or postoperative complications were collected prospectively. RESULTS: Five of the initial 264 patients died during the immediate postoperative course, and 107 within 6 months. At 1 year, 57 patients remained alive. Twenty-six (10%) were lost to follow-up. Preoperative albuminemia<35g/L (29% of patients), calcemia>2.6 nmol/L (8%) and CRP>10mg/L (47.5%) were associated with significantly elevated mortality. Only CRP elevation correlated with postoperative complications rate. CONCLUSION: The study confirmed the prognostic value of 3 biologic parameters (CRP level, albuminemia, calcemia) for survival after spinal bone metastasis surgery. A hybrid score taking account of not only clinical but also biologic parameters should be developed to improve estimation of survival.

Screw-Related Complications After Instrumentation of the Osteoporotic Spine: A Systematic Literature Review With Meta-Analysis.

STUDY DESIGN: Systematic literature review with meta-analysis. OBJECTIVE: Osteoporosis is common in elderly patients, who frequently suffer from spinal fractures or degenerative diseases and often require surgical treatment with spinal instrumentation. Diminished bone quality impairs primary screw purchase, which may lead to loosening and its sequelae, in the worst case, revision surgery. Information about the incidence of spinal instrumentation-related complications in osteoporotic patients is currently limited to individual reports. We conducted a systematic literature review with the aim of quantifying the incidence of screw loosening in osteoporotic spines. METHODS: Publications on spinal instrumentation of osteoporotic patients reporting screw-related complications were identified in 3 databases. Data on screw loosening and other local complications was collected. Pooled risks of experiencing such complications were estimated with random effects models. Risk of bias in the individual studies was assessed with an adapted McHarm Scale. RESULTS: From 1831 initial matches, 32 were eligible and 19 reported screw loosening rates. Studies were heterogeneous concerning procedures performed and risk of bias. Screw loosening incidences were variable with a pooled risk of 22.5% (95% CI 10.8%-36.6%, 95% prediction interval [PI] 0%-81.2%) in reports on nonaugmented screws and 2.2% (95% CI 0.0%-7.2%, 95% PI 0%-25.1%) in reports on augmented screws. CONCLUSIONS: The findings of this meta-analysis suggest that screw loosening incidences may be considerably higher in osteoporotic spines than with normal bone mineral density. Screw augmentation may reduce loosening rates; however, this requires confirmation through clinical studies. Standardized reporting of prespecified complications should be enforced by publishers.

Cervical and thoracic spine tumor management: surgical indications, techniques, and outcomes.

Since the first pioneering work in the area of tumors of the spine, medical professionals have sought to determine the proper role of spine surgery in the management of spinal tumors. Experience has proven that spine surgery is effective in the treatment of spinal cord compression for decreasing pain and improving quality of life with low rates of surgical complications. We use several staging systems to assess the patient's prognosis, to determine the best type of tumoral resection in preoperative surgical planning, and to provide guidance as to the best therapeutic option for the patient. In the surgical treatment of spine tumors, one of two opposing strategies must be chosen: (1) palliative surgery with cord decompression and spine stabilization or (2) curative surgery with en bloc radical resection of the tumor and stabilization. In this article, we describe indications and surgical techniques related to cervical spinal tumors: fixation and laminectomy of the upper and lower cervical spines, corporectomy, and partial and total vertebrectomy. For tumors of the cervicothoracic region, the most frequent level of spine metastasis and thoracic spine tumors, we describe the fixation and laminectomy technique, en bloc tumor resection, and partial and total vertebrectomy. The last part of the article addresses outcomes following spinal surgery, including outcomes related to en bloc Pancoast Tobias tumor resection, malignant dumbbell schwanomas, and metastasis.

A novel risk calculator to predict outcome after surgery for symptomatic spinal metastases; use of a large prospective patient database to personalise surgical management.

AIM: Surgery for spinal metastases can improve symptoms, but sometimes complications can negate the benefits. Operations may have different indications, complexities and risks, and the choice for an individual is a tailor-made personalised decision. Previous prognostic scoring systems are becoming out of date and inaccurate. We designed a risk calculator to estimate survival after surgery, to inform clinicians and patients when making management decisions. METHODS: A prospective cohort study was performed, including 1430 patients with spinal metastases who underwent surgery. Of them, 1264 patients from 20 centres were used for model development using a Cox frailty model. Calibration slope, D-statistic and C-index were used for model validation based on 166 patients. Follow-up was to death or minimum of 2 years after surgery. Pre-operative indices (examination findings, pain, Karnofsky physical functioning score, and radiology) were assessed. RESULTS: An algorithm to predict survival was constructed including the tumour type, ambulatory status, analgesic use, American Society of Anesthesiologists score, number of spinal metastases, previous radiotherapy or chemotherapy, presence of visceral metastases, cervical or thoracic spine involvement, as predictors. An Internet-based risk calculator was developed based on this algorithm, with similar or improved accuracy compared to other validated prognostic scoring systems (C-index, 0.68; 95% confidence interval, 0.63--0.73, and calibration slope, 1.00; 95% confidence interval, 0.68--1.32). CONCLUSION: A large, prospective, surgical series of patients with symptomatic spinal metastases was used to create a validated risk calculator that can help clinicians to inform patients about the most appropriate treatment plan. The calculator is available at www.spinemet.com.

Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007.

OBJECT: Opinions vary widely as to the role of surgery (from none to wide margin excision) in the management of spinal metastases. In this study the authors set out to ascertain if surgery improves the quality of remaining life in patients with spinal metastatic and tumor-related systemic disease. METHODS: The authors included 223 patients in this study who were referred by oncologists and physicians over a 2-year period. All underwent surgery. Surgery was classified according to extent of excision ranging from en bloc excision or debulking to palliative surgery. All patients had a histologically confirmed diagnosis of epithelial spinal metastasis, and an oncology specialist undertook appropriately indicated adjuvant therapy in almost half of the patients. RESULTS: The mean patient age was 61 years. Excisional en bloc or debulking surgery was performed in 74%; the rest had (minimal) palliative decompression. All patients considered for surgery were included in the study. Patients presented with pain in 92% of cases, paraparesis in 24%, and abnormal urinary sphincter function in 22% (5% were incontinent). Breast, renal, lung, and prostate accounted for 65% of the cancers, and in 60% of patients there were widespread spinal metastases (Tomita Type 6 or 7). The incidence of perioperative death (within 30 days of surgery) was 5.8%. Postoperatively 71% of the entire group had improved pain control, 53% regained or maintained their independent mobility, and 39% regained urinary sphincter function. The median survival for the cohort was 352 days (11.7 months); those who underwent excision survived significantly longer than those in the palliative group (p = 0.003). As with survival results, functional improvement outcome was better in those who underwent excision. CONCLUSIONS: Surgical treatment was effective in improving quality of life by providing better pain control, enabling patients to regain or maintain mobility, and offering improved sphincter control. Although not a treatment of the systemic cancer, surgery is feasible, has acceptably low mortality and morbidity rates, and for many will improve the quality of their remaining life.

The Intervertebral Disc: Physiology and Pathology of a Brittle Joint.

BACKGROUND: Intervertebral disc (ID) degeneration represents the number one cause for outpatient clinic visits worldwide. Mechanisms are discussed but not yet clearly established. Consequently, back pain management is commonly limited to symptomatic treatment therapies. OBJECTIVES: The aim of this review is to evaluate major progress and to unravel the biology and pathology of ID discogenic pain. METHODS: The design of this study is a systematic review. A literature search was conducted using Medline, EMBASE, and Google Scholar databases, with no time constraints to locate relevant literature. Significant articles (literature reviews, therapeutic essays, clinical-human-research studies, animal research, and laboratory research) on the intervertebral disc were identified and reviewed. The exclusion criteria were the following: case reports and clinical studies with <10 patients. RESULTS: Through a dense review of the literature, the ID is deciphered and described as a fragile anatomic entity. For this systematic review, 132 studies were identified and 79 were retained. The main deterioration and alteration mechanisms that lead to the programmed death of the ID are summarized. In addition, the large variety of biological therapies that override surgical treatment are determined. CONCLUSIONS: The degeneration mechanisms of the ID are well defined and decrypted. Although therapies have progressed, none has been effective. The regeneration of the ID remains highly challenging because of the complexity of its natural composition, microstructure, and mechanical properties.

Prediction Accuracy of Common Prognostic Scoring Systems for Metastatic Spine Disease: Results of a Prospective International Multicentre Study of 1469 Patients.

STUDY DESIGN: A prospective multicenter cohort study. OBJECTIVE: To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases. SUMMARY OF BACKGROUND DATA: There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems. METHODS: We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival. RESULTS: All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66. CONCLUSION: No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation. LEVEL OF EVIDENCE: 3.

Metastatic Spine Tumor Epidemiology: Comparison of Trends in Surgery Across Two Decades and Three Continents.

BACKGROUND: Indications for surgery for symptomatic spinal metastases have become better defined in recent years, and suitable outcome measures have been established against a changing backdrop of patient characteristics, tumor behavior, and oncologic treatments. Nonetheless, variations still exist in the local management of patients with spinal metastases. In this study, we aimed to review global trends and habits in the surgical treatment of symptomatic spinal metastases, and to examine how these have changed over the last 25 years. METHODS: In this cohort study of consecutive patients undergoing surgery for symptomatic spinal metastases, data were collected using a secure Internet database from 22 centers across 3 continents. All patients were invited to participate in the study, except those unable or unwilling to give consent. RESULTS: There was a higher incidence of colonic, liver, and lung carcinoma metastases in Asian countries, and more frequent presentation of breast, prostate, melanoma metastases in the West. Trends in surgical technique were broadly similar across the centers. Overall survival rates after surgery were 53% at 1 year, 31% at 2 years, and 10% at 5 years after surgery (standard error 0.013 for all). Survival improved over successive time periods, with longer survival in patients who underwent surgery in 2011-2016 compared with those who underwent surgery in earlier time periods. CONCLUSIONS: Surgical habits have been fairly consistent among countries worldwide and over time. However, patient survival has improved in later years, perhaps due to medical advances in the treatment of cancer, improved patient selection, and operating earlier in the course of disease.

Loss of Local Tumor Control After Index Surgery for Spinal Metastases: A Prospective Cohort Study.

BACKGROUND: As survival after treatment for symptomatic spinal metastases increases, the incidence of local tumor recurrence also may increase. However, data regarding incidence and timing of recurrence or duration of survival after second surgeries are not readily available and may help to inform clinicians when to perform second surgeries. OBJECTIVE: To identify features associated with loss of local control (LLC) at a previously treated or new spinal level. METHODS: Clinical and surgical data were collected from a prospective cohort of 1421 patients who had surgery for symptomatic spinal metastases. Patients undergoing repeat spinal surgery for symptomatic LLC at the same or a different level were identified and analyzed. RESULTS: In total, 3.0% patients underwent repeat surgery for symptomatic LLC after a median interval of 184 days from the first surgery; median survival was 6.1 months after second surgery. Factors associated with second surgery for LLC were the primary tumor type, number of spinal levels, Tomita staging, Tokuhashi and Karnofsky scores, anterior surgical approach, more aggressive surgical resection, and postoperative radiotherapy. In total, 1.5% patients were admitted for surgery for a different spinal level than the index operation after median 338 days from the first operation. CONCLUSIONS: The likelihood for repeat surgery due to LLC cannot be accurately predicted at the time of initial presentation. Factors associated with second surgery for LLC relate to less aggressive tumor biology and better survival. Most patients had a reasonable duration of survival after second surgery.

Characteristics of Patients Who Survived < 3 Months or > 2 Years After Surgery for Spinal Metastases: Can We Avoid Inappropriate Patient Selection?

PURPOSE: Survival after metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with pathologic spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve quality of life. Surgery is generally considered to be inappropriate if anticipated survival is < 3 months. The aim of this international multicenter study was to analyze data from patients who died within 3 months or 2 years after surgery, to identify preoperative factors associated with poor or good survival, and to avoid inappropriate selection of patients for surgery in the future. PATIENTS AND METHODS: A total of 1,266 patients underwent surgery for impending pathologic fractures and/or neurologic deficits and were prospectively observed. Data collected included tumor characteristics, preoperative fitness (American Society of Anesthesiologists advisory [ASA]), neurologic status (Frankel scale), performance (Karnofsky performance score [KPS]), and quality of life (EuroQol five-dimensions questionnaire [EQ-5D]). Outcomes were survival at 3 months and 2 years postsurgery. Univariable and multivariable logistic regression analyses were used to find preoperative factors associated with short-term and long-term survival. RESULTS: In univariable analysis, age, emergency surgery, KPS, EQ-5D, ASA, Frankel, and Tokuhashi/Tomita scores were significantly associated with short survival. In multivariable analysis, KPS and age were significantly associated with short survival (odds ratio [OR], 1.36; 95% CI, 1.15 to 1.62; and OR, 1.14; 95% CI, 1.02 to 1.27, respectively). Associated with longer survival in univariable analysis were age, number of levels included in surgery, KPS, EQ-5D, Frankel, and Tokuhashi/Tomita scores. In multivariable analysis, the number of levels included in surgery (OR, 1.21; 95% CI, 1.06 to 1.38) and primary tumor type were significantly associated with longer survival. CONCLUSION: Poor performance status at presentation is the strongest indicator of poor short-term survival, whereas low disease load and favorable tumor histology are associated with longer-term survival.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment.

BACKGROUND: Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery. OBJECTIVE: To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases. METHODS: In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival. RESULTS: The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001). CONCLUSION: Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.

Radical en bloc resection for lung cancer invading the spine.

OBJECTIVE: We reviewed our 8-year experience with en bloc partial and total vertebrectomy for lung cancer invading the spine and report outcome and survival. METHODS: Nineteen patients with lung cancers involving the spine underwent en bloc resection. Eleven received induction treatment (chemotherapy, n = 5; chemoradiotherapy, n = 4; and radiation, n = 2). Pneumonectomy was performed in 3 patients, lobectomy in 13 patients, and wedge resection in 3 patients. Hemivertebrectomy was performed in 15 patients, and total vertebrectomy was performed in 4 patients. The median number of resected vertebral bodies was 3 (range, 1-4). Tumor stage was IIIB in 14 patients, IIIA in 1 patient, and IIB in 4 patients (hemivertebrectomy is performed in the case of T3 disease to obtain free margins). Surgical nodal status was N0 in 13 patients, N1 in 3 patients, N2 in 1 patient, and N3 (supraclavicular) in 2 patients. Complete macroscopic and microscopic resection was achieved in 15 (79%) patients. RESULTS: There was no immediate postoperative mortality. Morbidity was observed in 10 patients, including 4 (21%) complications related to the spinal surgery. The median hospital stay was 30 days. Seven patients were alive after a mean follow-up of 26 months (range, 7-74 months). The 1- and 5-year predicted survivals (updated) are 59% and 14%, respectively. Nine local recurrences were observed. CONCLUSIONS: En bloc resection of chest tumors with vertebrectomy is technically demanding, and postoperative morbidity should be critically addressed with this aggressive surgical intervention. However, an encouraging long-term survival observed in this series suggests that en bloc resection could be a valid option in selected patients with vertebral involvement of chest tumors.