Proton versus photon adjuvant radiotherapy: a multicenter comparative evaluation of recurrence following spinal chordoma resection.

OBJECTIVE: Chordomas are rare tumors of the skull base and spine believed to arise from the vestiges of the embryonic notochord. These tumors are locally aggressive and frequently recur following resection and adjuvant radiotherapy. Proton therapy has been introduced as a tissue-sparing option because of the higher level of precision that proton-beam techniques offer compared with traditional photon radiotherapy. This study aimed to compare recurrence in patients with chordomas receiving proton versus photon radiotherapy following resection by applying tree-based machine learning models. METHODS: The clinical records of all patients treated with resection followed by adjuvant proton or photon radiotherapy for chordoma at Mayo Clinic were reviewed. Patient demographics, type of surgery and radiotherapy, tumor recurrence, and other variables were extracted. Decision tree classifiers were trained and tested to predict long-term recurrence based on unseen data using an 80/20 split. RESULTS: Fifty-three patients with a mean ± SD age of 55.2 ± 13.4 years receiving surgery and adjuvant proton or photon therapy to treat chordoma were identified; most patients were male. Gross-total resection was achieved in 54.7% of cases. Proton therapy was the most common adjuvant radiotherapy (84.9%), followed by conventional or external-beam radiation therapy (9.4%) and stereotactic radiosurgery (5.7%). Patients receiving proton therapy exhibited a 40% likelihood of having recurrence, significantly lower than the 88% likelihood observed in those treated with nonproton therapy. This was confirmed on logistic regression analysis adjusted for extent of tumor resection and tumor location, which revealed that proton adjuvant radiotherapy was associated with a decreased risk of recurrence (OR 0.1, 95% CI 0.01-0.71; p = 0.047) compared with photon therapy. The decision tree algorithm predicted recurrence with an accuracy of 90% (95% CI 55.5%-99.8%), with the lowest risk of recurrence observed in patients receiving gross-total resection with adjuvant proton therapy (23%). CONCLUSIONS: Following resection, adjuvant proton therapy was associated with a lower risk of chordoma recurrence compared with photon therapy. The described machine learning models were able to predict tumor progression based on the extent of tumor resection and adjuvant radiotherapy modality used.

Single-Photon Emission Computed Tomography (SPECT-CT) as a Predictor of Pain Generators in Patients Undergoing Anterior Cervical Discectomy and Fusion (ACDF) for Axial Cervical Pain.

BACKGROUND: Axial neck pain is often associated with cervical instability, and surgical options are often reserved for patients with either neurological compromise or deformity of the spine. However, cervical facet arthropathy is often implicated with instability and the location of painful generators is often difficult to ascertain. Single-photon emission computed tomography (SPECT-CT) presents an adjunct to conventional imaging in the workup of patients with suspected facetogenic pain. We aimed to report our experience with patients undergoing anterior cervical discectomy and fusion (ACDF) guided by SPECT-CT for axial cervical pain. METHODS: We retrospectively identified all cases undergoing ACDF that presented with axial neck pain where correlating SPECT-CT high metabolism areas were identified. Patients were treated at a tertiary care institution between January 2018 and January 2021. Patients with positive radiotracer uptake pre-operatively were compared with patients undergoing ACDF without uptake on SPECT-CT. The pre- and post-operative patients who reported neck pain at one year were compared. RESULTS: Thirty-five patients were included in this retrospective cohort. The median pre- and post-intervention (at one-year follow-up) visual analog score (VAS) of patients undergoing ACDF without uptake on SPECT-CT was 7 and 3 (p<0.01), while the pre- and post-VAS for patients undergoing surgery with positive uptake on SPECT-CT was 8.5 and 0 (p<0.01). Improvement was significantly larger for patients undergoing SPECT-CT-guided ACDF (p=0.02). At one year after surgery, none of the assessed patients required additional surgical intervention. CONCLUSION: This case series represents the experience of our group to date with patients undergoing SPECT-CT-guided ACDF with results suggesting potential benefit in guiding fusion.

Frailty as a Predictor of Postoperative Morbidity and Mortality in Patients Aged 80 Years and Older Undergoing Instrumented Fusion.

BACKGROUND AND OBJECTIVES: Degenerative spine disease is a leading cause of disability, with increasing prevalence in the older patients. While age has been identified as an independent predictor of outcomes, its predictive value is limited for similar older patients. Here, we aimed to determine the most predictive frailty score of adverse events in patients aged 80 and older undergoing instrumented lumbar fusion. METHODS: We proceeded with a multisite (3 tertiary academic centers) retrospective review including patients undergoing instrumented fusion aged 80 and older from January 2010 to present. A composite end point encompassing 30-day return to operating room, readmission, and mortality was created. We estimated the area under the receiver operating characteristic curve for frailty scores (Modified Frailty Index-5 [MFI-5], Modified Frailty Index-11 [MFI-11], and Charlson Comorbidity Index [CCI]) in relation to that composite score. In addition, we estimated the association between each score and the composite end point by means of logistic regression. RESULTS: A total of 153 patients with an average age of 85 years at the time of surgery were included. We observed a 30-day readmission rate of 11.1%, reoperation of 3.9%, and mortality of 0.6%. The overall rate of the composite end point at 30 days was 25 (15.1%). The AUC for MFI-5 was 0.597 (0.501-0.693), for MFI-11 was 0.620 (0.518-0.723), and for CCI was 0.564 (0.453-0.675). The association between the scores and composite end point did not reach statistical significance for MFI-5 (odds ratio [OR] = 1.45 [0.98-2.15], P = .061) and CCI (OR = 1.13 [0.97-1.31], P = .113) but was statistically significant for MFI-11 (OR = 1.46 [1.07-2.00], P = .018). CONCLUSION: This is the largest study comparing frailty index scores in octogenarians undergoing instrumented lumbar fusion. Our findings suggest that while MFI-11 score correlated with adverse events, the predictive ability of existing scores remains limited, highlighting the need for better approaches to identify select patients at age extremes.

General Versus Nongeneral Anesthesia for Spinal Surgery: A Comparative National Analysis of Reimbursement Trends Over 10 Years.

BACKGROUND AND OBJECTIVES: Nongeneral anesthesia (non-GA) spine surgery is growing in popularity and has facilitated earlier postoperative recovery, reduced cost, and fewer complications compared with spine surgery under general anesthesia (GA). Changes in reimbursement policies have been demonstrated to correlate with clinical practice; however, they have yet to be studied for GA vs non-GA spine procedures. We aimed to investigate trends in physician reimbursement for GA vs non-GA spine surgery in the United States. METHODS: We queried the ACS-NSQIP for GA and non-GA (regional, epidural, spinal, and anesthesia care/intravenous sedation) spine surgeries during 2011-2020. Work relative value units per operative hour (wRVUs/h) were retrieved for decompression or stabilization of the cervical, thoracic, and lumbar spine. Propensity score matching (1:1) was performed using all baseline variables. RESULTS: We included 474 706 patients who underwent spine decompression or stabilization procedures. GA was used in 472 248 operations, whereas 2458 operations were non-GA. The proportion of non-GA spine operations significantly increased during the study period. Operative times ( P < .001) and length of stays ( P < .001) were shorter in non-GA when compared with GA procedures. Non-GA lumbar procedures had significantly higher wRVUs/h when compared with the same procedures performed under GA (decompression; P < .001 and stabilization; P = .039). However, the same could not be said about cervicothoracic procedures. Lumbar decompression surgeries using non-GA witnessed significant yearly increase in wRVUs/h ( P < .01) contrary to GA ( P = .72). Physician reimbursement remained stable for procedures of the cervical or thoracic spine regardless of the anesthesia. CONCLUSION: Non-GA lumbar decompressions and stabilizations are associated with higher and increasing reimbursement trends (wRVUs/h) compared with those under GA. Reimbursement for cervical and thoracic surgeries was equal regardless of the type of anesthesia and being relatively stable during the study period. The adoption of a non-GA technique relative to the GA increased significantly during the study period.

Surgical management of malignant melanotic nerve sheath tumors: an institutional experience and systematic review of the literature.

OBJECTIVE: Malignant melanotic nerve sheath tumors are rare tumors characterized by neoplastic melanin-producing Schwann cells. In this study, the authors report their institution's experience in treating spinal and peripheral malignant melanotic nerve sheath tumors and compare their results with the literature. METHODS: Data were collected from 8 patients who underwent surgical treatment for malignant melanotic nerve sheath tumors between 1996 and 2023 at Mayo Clinic and 63 patients from the literature. Time-to-event analyses were performed for the combined group of 71 cases to evaluate the risk of recurrence, metastasis, and death based on tumor location and type of treatment received. Unpaired 2-sample t-tests and Fisher's exact tests were used to determine statistical significance between groups. RESULTS: Between 1996 and 2023, 8 patients with malignant melanotic nerve sheath tumors underwent surgery at the authors' institution, while 63 patients were identified in the literature. The authors' patients and those in the literature had the same mean age at diagnosis (43 years). At the authors' institution, 5 patients (63%) experienced metastasis, 6 patients (75%) experienced long-term recurrence, and 5 patients (62.5%) died. In the literature, most patients (60.3%) were males, with a peak incidence between the 4th and 5th decades of life. Nineteen patients (31.1%) were diagnosed with Carney complex. Nerve root tumors accounted for most presentations (n = 39, 61.9%). Moreover, 24 patients (38.1%) had intradural lesions, with 54.2% (n = 13) being intramedullary and 45.8% (n = 11) extramedullary. Most patients underwent gross-total resection (GTR) (n = 41, 66.1%), followed by subtotal resection (STR) (n = 12, 19.4%), STR with radiation therapy (9.7%), and GTR with radiation therapy (4.8%). Sixteen patients (27.6%) experienced metastasis, 23 (39.7%) experienced recurrence, and 13 (22%) died. Kaplan-Meier analyses showed no significant differences among treatment approaches in terms of recurrence-free, metastasis-free, and overall survival (p > 0.05). Similar results were obtained when looking at the differences with respect to intradural versus nerve root location of the tumor (p > 0.05). CONCLUSIONS: Malignant melanotic nerve sheath tumors are rare tumors with a high potential for malignancy. They carry a dismal prognosis, with a pooled local recurrence rate of 42%, distant metastasis rate of 27%, and mortality rate of 26%. The findings from this study suggest a trend favoring the use of GTR alone or STR with radiation therapy over STR alone. Mortality was similar regardless, which highlights the need for the development of effective treatment options to improve survival in patients with melanotic schwannomas.

Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis.

BACKGROUND: Awake surgery, under spinal anesthesia (SA), is an alternative to surgery under general anesthesia (GA), in neurological and spine surgery. In the literature, there seem to be some evidence supporting benefits associated with the use of this anesthetic modality, as compared to GA. Currently, there is a notable lack of updated and comprehensive review addressing the complications associated with both awake SA and GA in spine surgery. We hence aimed to perform a systematic review of the literature and meta-analysis on the topic. METHODS: A systematic search was conducted to identify studies that assessed SA in spine surgery from database inception to April 14, 2023, in PubMed, Medline, Embase, and Cochrane databases. Outcomes of interest included estimated blood loss, length of hospital stay, operative time, and overall complications. Meta-analysis was conducted using random effects models. RESULTS: In total, 38 studies that assessed 7820 patients were included. The majority of the operations that were treated with SA were single-level lumbar cases. Awake patients had significantly shorter lengths of hospital stay (Mean difference (MD): - 0.40 days; 95% CI - 0.64 to - 0.17) and operative time (MD: - 19.17 min; 95% CI - 29.68 to - 8.65) compared to patients under GA. The overall complication rate was significantly higher in patients under GA than SA (RR, 0.59 [95% CI 0.47-0.74]). Patients under GA had significantly higher rates of postoperative nausea/vomiting RR, 0.60 [95% CI 0.39-0.90]) and urinary retention (RR, 0.61 [95% CI 0.37-0.99]). CONCLUSIONS: Patients undergoing awake spine surgery under SA had significantly shorter operations and hospital stays, and fewer rates of postoperative nausea and urinary retention as compared to GA. In summary, awake spine surgery offers a valid alternative to GA and added benefits in terms of postsurgical complications, while being associated with relatively low morbidity.

Impact of postoperative fatigue following minimally-invasive lumbar spine surgery.

BACKGROUND: Postoperative fatigue is a distressing symptom and can have a major impact on the patient's quality of life after surgery. We investigate the extent of postoperative fatigue following minimally invasive spine surgery under general anesthesia (GA), and its impact on patients' quality of life (QOL) and activities of daily living (ADLs). METHODS: We surveyed patients that underwent minimally-invasive lumbar spine surgery under GA within the previous year. A five-point Likert scale ("very much", "quite a bit", "somewhat", "a little bit", "not at all") was used to assess the extent of fatigue during the first postoperative month, its impact on QOL, and ADLs. RESULTS: The survey was completed by 100 patients, 61% were male, mean age 64.6 ± 12.5 years, 31% underwent MIS-TLIF, 69% lumbar laminectomy. During the first postoperative month 45% of patients referred significant fatigue ("very much" or "quite a bit"); for 31% of patients fatigue significantly impacted their QOL; significantly limited their ADLs in 43% of patients. MIS-TLIF was associated with higher rate of postoperative fatigue compared to laminectomy (61.3% versus 37.7%, p = 0.02). Patients 65 years old or older had higher rates of fatigue compared to younger patients (55.6% versus 32.6%, p = 0.02). We did not observe a significant difference in postoperative fatigue between male and female patients. CONCLUSIONS: Our study revealed a substantial incidence of postoperative fatigue in patients that underwent minimally-invasive lumbar spine surgery under GA, with a significant impact on QOL and ADLs. There is a need to research new strategies to reduce fatigue after spine surgery.

Reliability of YouTube videos on robotic spine surgery for patient education.

BACKGROUND: Robotic surgical systems developed to improve spine surgery accuracy. Studies have found significant reductions in screw revisions and radiation exposure with robotic assistance compared with open surgery. YouTube is the largest online video platform for medical education. Therefore, there is a need for the continuous critical assessment of healthcare-related YouTube videos. Our objective is to assess the reliability of YouTube videos on robotic spine surgery for patient education. METHODS: In April of 2022, YouTube was queried for the following keywords: "Robotic Spine Surgery". The "Relevance-Based Ranking" filter was applied, and the first 3 result pages were considered. Videos had to be uploaded by universities or hospitals and be in the English. Three independent healthcare personnel evaluated the videos' education quality using the DISCERN tool. RESULTS: Our study found that 33 % of videos analyzed scored above a 3 on the DISCERN scoring scale (considered a ''good" video), with overall mean DISCERN score of 2.8 ± 1.3 (SD). The duration of videos was significantly different between the two groups (Good = 16 min ± 21 vs Unhelpful = 4 min ± 4, p = 0.01). In the helpful group, other characteristics were number of views (16331 ± 31308), likes (88 ± 168) and dislikes (5 ± 8). No statistically significant differences were observed compared to the unhelpful group: number of views (6515 ± 9074; P = 0.20), likes (39 ± 55; P = 0.21) and dislikes (3 ± 4; P = 0.33). CONCLUSION: Our study shows that YouTube videos on robotic spine surgery lack accuracy and have poor educational value. There should be increased institutional oversight to combat the spread of misinformation.

Two- versus multi-rod constructs for adult spinal deformity: A systematic review and Random-effects and Bayesian meta-analysis.

BACKGROUND: Surgical approaches in adult spinal deformity are associated with high rates of adverse events including hardware failure and rod fracture. Recently, some reports have emerged comparing multiple-rod constructs with 2-rod constructs suggesting potential benefits with the former. However, these have been limited by variability in observed outcomes, which have limited the change of paradigm in adult spinal deformity surgery. OBJECTIVE: To compare the rate of rod fracture, pseudoarthrosis, proximal junctional kyphosis and re-operation between 2-RC and M-RC. METHODS: MEDLINE/Pubmed, Web of Science and Embase were searched without language restrictions for relevant articles from inception until October 2021. All observational cohort studies assessing patients with ADS undergoing 3-column osteotomy and comparing 2-RC with M-RC procedures on pseudarthrosis, rod fracture, kyphosis or reoperation were included. Data were independently extracted by 2 authors. Random-effects and Bayesian meta-analysis were used. RESULTS: Six primary studies met inclusion criteria, yielding a total of 448 participants, with 223 receiving 2-RC and 225 M-RC. The random-effects meta-analysis pointed to a significantly lower risk of rod fracture associated with M-RC (RR = 0.43, 95 %CI = 0.28-0.66), with moderate heterogeneity being observed (I2 = 20 %, p = 0.28). The random-effects meta-analysis pointed to a lower risk of pseudoarthrosis with M-RC than with 2-RC (RR = 0.49, CI = 0.28-0.84, to a lower rate of re-operation with M-RC than with 2-RC (RR = 0.52, CI = 0.28-0.97) and to a similar rate of proximal junctional kyphosis between 2-RC and M-RC patients (RR = 0.91, CI = 0.60-1.39). Low heterogeneity was observed for studies comparing pseudoarthrosis (I2 = 9 %, p = 0.35), re-operation (I2 = 0 %, p = 0.41) and proximal junctional kyphosis (I2 = 0 %, p = 0.85). DISCUSSION: These findings suggest that multiple rod-fracture constructs are associated with lower rates of rod fracture, re-operation rates, pseudoarthrosis but not proximal junctional kyphosis. Future studies should address the impact of other modulators of heterogeneity such as body mass index, metal alloys and length of the constructs.

Assessment of surgeons' attitude towards awake spine surgery under spinal anesthesia.

BACKGROUND: General anesthesia (GA) and spinal anesthesia (SA) have been adopted for lumbar spine surgery (LSS), but GA is used far more widely. We conducted a survey of spine surgeons to explore their attitudes and preferences regarding awake spine surgery under SA. METHODS: A survey was emailed to 150 spine surgeons. Exposure and attitudes towards spine surgery under SA were elicited. A five-point Likert scale of agreement examined perceptions of SA, while attitudes towards SA were recorded by categorizing free text into themes. RESULTS: Seventy-five surgeons completed the survey, 50 % response rate. Only 27 % said they perform LSS under SA. Most surgeons, 83 %, would recommend GA to a healthy patient undergoing lumbar laminectomy. Only 41 % believes SA to be as safe as GA, and only 30 % believes SA is associated with better postoperative pain control. The most common reasons why SA is not favored was lack of proven benefits over GA (65 %). When asked if a randomized trial finds SA to lead to less postoperative fatigue, 50 % said they would be more likely to offer SA, a significant increase from the baseline response of 27 % (p = 0.002). CONCLUSIONS: Our survey indicates that the low adoption of SA for LSS is due to lack of surgeons' belief in the benefits of SA over GA, and that a randomized patient-centered trial has the potential of changing surgeons' perspective and increasing adoption of SA for LSS.

Resolution of atlanto-occipital cyst with conservative management: A case report and review of the literature.

Background: Spinal synovial cysts are cystic dilatations of synovial sheaths that extrude into the spinal canal. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures. They are most commonly found in the lumbar spine and are rare in the cervical region, especially at the atlanto-occipital junction. Case Description: A 65-year-old presented with neck pain and headaches. The magnetic resonance imaging (MRI) revealed a degenerative cyst within the anterior foramen magnum causing anterior spinal cord and brainstem compression. Multiple surgical treatment options were discussed, and he was prescribed methylprednisolone and immobilization of his cervical spine with a rigid collar. One month later, the patient reported dramatic improvement of his symptoms, and no surgery was performed. One year later, his pain had remained much improved with the continued use of the collar and pain management (i.e., using anti-inflammatories and muscle relaxants). The 1-year follow-up MRI showed the atlanto-occipital cyst compressing the cervicomedullary junction had completely resolved along with the brainstem compression. Conclusion: A 65-year-old presented with myelopathy attributed to a large anterior foramen magnum atlanto-occipital cyst compressing the cord. Conservative management for 1 month with a rigid cervical collar and steroids resulted in marked neurological improvement; at 1 year follow-up, the patient was markedly improved with an MR that demonstrated spontaneous cyst regression.

Disease characteristics and patterns of familial colloid cyst of the third ventricle: An international survey of the Colloid Cyst Survivors Group.

BACKGROUND: Colloid cysts of the third ventricle are rare benign tumors, accounting for approximately 1% of all intracranial tumors. Familial colloid cysts are less common, only 25 cases have been previously reported in the literature. We aim to describe demographic and disease-specific characteristics to reduce the knowledge gap with this potentially life-threatening tumor. METHODS: We conducted a retrospective cohort study of 211 colloid cyst patients from the Colloid Cyst Survivors Group who completed a survey that included demographicandclinical data andinquired aboutfamily members diagnosed with a colloid cyst. Datawascollected from October 14th, 2021 to October 27th, 2021. We compared our data with previously published cases from the literature. RESULTS: A total of 211 responses from patients with a previous diagnosis of a colloid cyst completed our survey. 11.8 % were familial colloid cysts, of this group 60.8 % were symptomatic and 39.2 % incidental. We observed significant difference between symptom incidence between reports from the literature and our cohort: headache 75.5 % versus 49 % (p = 0.005); imbalance 13.2 % versus 31.4 % (p = 0.03); nausea 11.3 % versus 29.4 % (p = 0.02), and difficulty walking 1.9 % versus 19.6 % (p = 0.003). Additionally, we found first degree family member as the most frequent relative diagnosed with this disease. CONCLUSION: Our study involved the largestcohortof patients with familial colloid cysts. According to previous literature, siblings are the most prevalent family member affected by this disease, specifically among monozygotic twins. This suggests strong inheritance patterns and even genetic mechanism underlying the development of this disease.

Interactive Neurosurgery Lecture Series: A Global Education Platform of Tele-Teaching During the Coronavirus Disease 2019 Pandemic and Beyond.

OBJECTIVE: To explore the worldwide impact of a virtual neurosurgery-neuroscience lecture series on optimizing neurosurgical education with tele-teaching. METHODS: A retrospective analysis was performed from our Zoom database to collect data from October 15, 2020, to December 14, 2020, and from September 27, 2021, to December 13, 2021. A comparative analysis of participants in the 2 different time frames was performed to investigate the impact of tele-teaching on neurosurgical education worldwide. To evaluate participant satisfaction, the yearly continuing medical education reports of 2020-2021 were analyzed. Data related to the distribution of lectures by subspecialties were also described. RESULTS: Among the 11 lectures of the first period, 257 participants from 17 countries in 4 different continents were recorded, with a mean of 64 (standard deviation = 9.30) participants for each meeting; 342 attendees participated from 19 countries in 5 continents over the 11 lectures of the second part, with an average of 82.8 (standard deviation = 14.04) attendees; a statistically significant increase in participation between the 2 periods was identified (P < 0.001) A total of 19 (2020) and 21 (2021) participants submitted the continuing medical education yearly survey. More than 86.4% of overall responses considered the lectures "excellent." The main topics reported during lectures in 2020-2021 were related to brain tumors (33.7%) and education (22.1%). CONCLUSIONS: The COVID-19 pandemic has increased the need to introduce new educational approaches for teaching novel ways to optimize patient care. Our multidisciplinary Web-based virtual lecture series could represent an innovative tele-teaching platform in neurosurgical training.

SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain.

BACKGROUND: The ability to accurately predict pain generators for chronic neck and back pain remains elusive. OBJECTIVE: We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain. METHODS: A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level. RESULTS: A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010). CONCLUSION: This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections.

Assessment of Patients' Willingness to Participate in a Randomized Trial of Spinal versus General Anesthesia for Lumbar Spine Surgery.

BACKGROUND: Prospective nonrandomized studies have found less postoperative fatigue and improved quality of life in patients undergoing awake spine surgery under spinal anesthesia compared with general anesthesia. Randomized trials are needed to validate these findings. OBJECTIVE: To prospectively investigate patients' willingness to enroll in randomized trials of lumbar spine surgery under spinal versus general anesthesia and identify any potential barriers. METHODS: We recruited patients undergoing lumbar spine surgery for degenerative disease. We described a randomized trial of spine surgery under spinal versus general anesthesia and assessed patients' willingness to participate in such trial. We elicited preferences for treatment along with demographics. The association between these factors and willingness to participate in the trial was examined. RESULTS: Fifty patients completed interviews; 58% were female, mean age of 60.9 ± 12.5 years. A total of 52% patients stated that they were definitely willing to participate in the hypothetical randomized trial, and 8% probably willing. Only 16% of patients were aware of spinal anesthesia as an option for low back surgery, and 60% indicated no strong preference for the anesthesia techniques. Patients without strong preferences stated a greater willingness to participate than those with strong preferences (80% vs. 10% definitely willing, P < 0.0001). Age, sex, education, work status, and race were not significantly associated with willingness to participate. CONCLUSION: Sixty percent of patients stated that they were either definitely or probably willing to participate in the randomized trial. Subjects lacking strong preferences for the anesthesia technique stated a greater willingness to enroll than those with strong preference.

Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis?

INTRODUCTION: Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS: We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS: After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION: Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.

Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis.

BACKGROUND: Management of degenerative disease of the spine has evolved to favor minimally invasive techniques, including nonrobotic-assisted and robotic-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Value-based spending is being increasingly implemented to control rising costs in the US healthcare system. With an aging population, it is fundamental to understand which procedure(s) may be most cost-effective. OBJECTIVE: To compare robotic and nonrobotic MIS-TLIF through a cost-utility analysis. METHODS: We considered direct medical costs related to surgical intervention and to the hospital stay, as well as 1-yr utilities. We estimated costs by assessing all cases involving adults undergoing robotic surgery at a single institution and an equal number of patients undergoing nonrobotic surgery, matched by demographic and clinical characteristics. We adopted a willingness to pay of $50 000/quality-adjusted life year (QALY). Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. RESULTS: Costs were estimated based on a total of 76 patients, including 38 undergoing robot-assisted and 38 matched patients undergoing nonrobot MIS-TLIF. Using point estimates, robotic surgery was projected to cost $21 546.80 and to be associated with 0.68 QALY, and nonrobotic surgery was projected to cost $22 398.98 and to be associated with 0.67 QALY. Robotic surgery was found to be more cost-effective strategy, with cost-effectiveness being sensitive operating room/materials and room costs. Probabilistic sensitivity analysis identified robotic surgery as cost-effective in 63% of simulations. CONCLUSION: Our results suggest that at a willingness to pay of $50 000/QALY, robotic-assisted MIS-TLIF was cost-effective in 63% of simulations. Cost-effectiveness depends on operating room and room (admission) costs, with potentially different results under distinct neurosurgical practices.

Spine Surgery Under Spinal vs General Anesthesia: Prospective Analysis of Quality of Life, Fatigue, and Cognition.

BACKGROUND: There has recently been increasing interest in the use of spinal anesthesia (SA) for spine surgery. The literature that compared spine surgery under SA vs general anesthesia (GA) focused on safety, perioperative outcomes, and costs. OBJECTIVE: To test if SA is associated with less postoperative fatigue, cognitive dysfunction, and better quality of life in patients undergoing lumbar spine surgery compared with GA. METHODS: We conducted a prospective nonrandomized study in patients undergoing elective lumbar spine surgery under SA or GA by a single surgeon. Fatigue was assessed with the fatigue visual analog scale scale (0-10) and Chalder Fatigue Scale, quality of life with Medical Outcomes Study 12-item Short Form (SF-12), and differences in cognition with Mini-Mental State Examination. Patients were baselined before surgery and assessed again 1 mo after surgery. RESULTS: Fifty patients completed the study, 25 underwent surgery under SA and 25 under GA. The groups were homogeneous for baseline clinical characteristics, with no differences in preoperative fatigue, quality of life, and cognition. At 1 mo after surgery, SA compared with GA had better fatigue scores: fatigue visual analog scale (2.9 ± 1.5 vs 5.9 ± 2.3 [P < .0001]) and Chalder Fatigue Scale (11.2 ± 3.1 vs 16.9 ± 3.9 [P < .0001]). One month postoperatively, we observed a significant difference in the SF-12 physical component, with SA having 38.8 ± 8.9 vs 29.4 ± 10.3 (P = .002). We did not observe significant postoperative differences in the SF-12 mental component or Mini-Mental State Examination. CONCLUSION: Our study demonstrates that SA offers unique patient-centered advantages to GA for elective spine surgery. One month after surgery, patients who received SA had less postoperative fatigue and better quality of life.

Emergency Airway Management During Awake Craniotomy: Comparison of 5 Techniques in a Cadaveric Model.

BACKGROUND: During awake craniotomy, securing the patient's airway might be necessary electively or emergently. The objective of this study was to compare the feasibility of airway management using a laryngeal mask airway (LMA) and 4 alternative airway management techniques in an awake craniotomy simulation. METHODS: After completing a questionnaire, 9 anesthesia providers attempted airway management in a cadaver positioned to simulate awake craniotomy conditions. Following the simulation, participants rated and ranked the devices in their order of preference. RESULTS: Only 3 approaches resulted in the successful securement of an airway device for 100% of participants: LMA (median; interquartile range time to secure the airway 6 s, 5 to 10 s), fiberoptic bronchoscopy through an LMA (41 s; 23 to 51 s), and video laryngoscopy (49 s; 43 to 127 s). In contrast, the oral and nasal fiberoptic approaches demonstrated only 44.4% (154.5 s; 134.25 to 182 s) and 55.6% (75 s; 50 to 117 s) success rates, respectively. The LMA was the fastest and most reliable primary method to secure the airway (P=0.001). After the simulation, 100% of participants reported that an LMA would be their first choice for emergency airway management, followed by fiberoptic intubation through the LMA (7 of 9 participants) if the LMA failed to properly seat. CONCLUSIONS: We demonstrated that an LMA was the fastest and most reliable primary method to secure an airway in a laterally positioned cadaver with 3-pin skull fixation. Fiberoptic and video laryngoscope airway equipment should be readily available during awake craniotomy procedures, and an attempt to visualize the vocal cords through the LMA should be attempted before removing it for alternative techniques.