Surgical site infection rates in open versus endoscopic lumbar spinal decompression surgery: A retrospective cohort study.

Background: Lumbar decompression is a commonly performed procedure for the operative management of several degenerative lumbar spinal pathologies. Although open approaches are considered the traditional method, endoscopic techniques represent a relatively novel, less-invasive option to achieve neural element decompression. Here within, we examine if the use of endoscopic techniques decreases the risk of post operative infections. Methods: We performed a retrospective cohort analysis to directly compare patients who underwent either open or endoscopic lumbar decompression at a single institution. Rates of postoperative outcomes such as surgical site infection, hospital length of stay, estimated blood loss, and others were compared between the two treatment groups. A multivariate logistic regression model was constructed using patient comorbidities and procedural characteristics to identify the risk factors for surgical site infection. Results: 150 patients were identified as undergoing lumbar spine decompression surgeries that met inclusion criteria for the study, of whom 108 (72.0%) underwent open and 61 (28.0%) underwent endoscopic approaches. Unpaired analysis revealed positive associations between operative duration, estimated blood loss, drain placement rates. Multivariate logistic regression did not reveal an association between surgical approach (open versus endoscopic) and the development of surgical site infection. Conclusions: Surgical site infections following endoscopic lumbar spine decompression are relatively uncommon, however, after adjusting for baseline differences between patient populations, surgical approach does not independently predict the development of postoperative infection.

The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Determine if tobacco use is associated with increased risk of postoperative adverse events within 90 days in patients undergoing spinal fusion surgery. METHODS: Databases were queried to identify cohort studies that directly compared smokers with non-smokers and provided the absolute number of adverse events and the population at risk. Data quality was evaluated using the Quality in Prognosis Studies tool. Risk ratios (RR) and 95% confidence intervals were calculated and compared between studies. The grading of recommendation, assessment, development and evaluation (GRADE) criteria were used to assess the strength of the evidence. RESULTS: Seventeen studies assessing 37 897 participants met the inclusion criteria. Of these, 10 031 (26.5%) were smokers and 27 866 (73.5%) were nonsmokers. The mean age for the study population was 58 years, and 45% were males. Smoking was not associated with increased risk of one or more major adverse events within 90 days following spine surgery (seven studies, pooled RR 1.13, 95% CI [.75-1.71], I2 = 41%). However, smoking was significantly associated with one or more major adverse events in ≤2 level fusion (three studies, pooled RR 2.46, 95% CI [1.18-5.12], I2 = 0%), but not in fusions of ≥3 levels (four studies, pooled RR .87, 95% CI [.70-1.08], I2 = 0%). Additionally, there was no statistically significant association between smoking and any adverse event, nor increased reoperation risk due to adverse events. CONCLUSIONS: In this meta-analysis, tobacco use was not associated with a statistically significant increased risk of adverse events within 90 days in patients undergoing spinal fusion surgery. Our results are limited by the variable reporting methodology for both complication rates as well as smoking incidence between the included individual studies.

Incidence, Management, and Outcomes of Adult Spinal Chordoma Patients in the United States.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Spinal chordomas are rare primary malignant neoplasms of the primitive notochord. They are slow growing but locally aggressive lesions that have high rates of recurrence and metastasis after treatment. Gold standard treatment remains en-bloc surgical resection with questionable efficacy of adjuvant therapies such as radiation and chemotherapy. Here we provide a comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with spinal chordoma. METHODS: Patients with diagnosis codes specific for chordoma of spine, sacrum, and coccyx were queried from the National Cancer Database (NCDB) during the years 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS: 1,548 individuals were identified with a diagnosis of chordoma, 60.9% of which were at the sacrum or coccyx and 39.1% at the spine. The mean overall survival of patients in our cohort was 8.2 years. Increased age, larger tumor size, and presence of metastases were associated with worsened overall survival. 71.2% of patients received surgical intervention and both partial and radical resection were associated with significantly improved overall survival (P < 0.001). Neither radiotherapy nor chemotherapy administration improved overall survival; however, amongst patients who received radiation, those who received proton-based radiation had significantly improved overall survival compared to traditional radiation. CONCLUSION: Surgical resection significantly improves overall survival in patients with spinal chordoma. In those patients receiving radiation, those who receive proton-based modalities have improved overall survival. Further studies into proton radiotherapy doses are required.

Chordoma of the Skull Base: A National Cancer Database Analysis of Current Practice Patterns and Outcomes.

BACKGROUND: Chordomas of the skull base are aggressive locally destructive tumors that arise from the remnants of the fetal notochord. Current guidelines recommend maximal safe surgical resection followed by adjuvant radiation therapy. However, because of the rarity of these tumors, the optimal radiotherapeutic regimen regarding dose and modality is unclear. METHODS: The National Cancer Database (NCDB) was queried from 2004 to 2016. Data from adult patients were extracted, including tumor characteristics, comorbidity indices, and details of treatment (surgery, radiation, and chemotherapy). The primary outcome of interest was overall survival (OS), which was evaluated for specific treatment cohorts using Cox univariate and multivariate regression constructs along with associated survival curves. RESULTS: We identified 798 patients with a diagnosis of skull base chordoma. Mean OS in this cohort was 9.57 years. Most patients received surgical resection (89.1%), with 53.9% receiving radiotherapy and 6.5% receiving chemotherapy. After adjusting for baseline characteristics using multivariate regression, advanced age and increased tumor size were associated with decreased OS. Surgical resection was associated with increased OS, whereas neither radiotherapy nor chemotherapy was associated with OS. However, in patients who did receive radiation, dosage >6000 cGy was associated with increased OS (hazard ratio, 0.51; P = 0.038); OS did not vary significantly between traditional and proton-based methods. CONCLUSIONS: Our multi-institutional analysis supports the use of partial and radical surgical resection to improve survival in patients with skull base chordomas. Among patients who receive radiotherapy, higher radiation dose is associated with improved survival.

Vasoplegia Following Complex Spine Surgery: Incidence and Risk.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Vasoplegia is a life-threatening form of distributive or vasodilatory shock that is characterized by reduced systemic vascular resistance with resultant hypotension and normal to elevated cardiac output affecting morbidity and mortality. Vasoplegia in the context of Spine Surgery has not been described previously. The purpose of this case series is to determine incidence, risk factors, complications and postoperative outcome in patients with vasoplegia after complex multi-level thoraco-lumbar spine surgery. METHODS: A retrospective review of the electronic medical records at our institution was conducted between January 2014 and June 2018. All patients undergoing multi-level spine surgery (>6 levels) were screened for intraoperative hypotension. Patient demographics, surgical characteristics, neurological status, blood loss, risk factors, medical treatment, complications, hospital course and mortality were collected. All patients included in this study had a minimum follow-up period of 3 months. RESULTS: Out of 8521 surgically treated patients, 994 patients with multi-level thoraco-lumbar spine surgery were identified. A total of 41 patients had intraoperative hypotensive events. Of those, 5 patients with vasoplegia could be identified after elimination of all other potential contributing factors. Vasoplegia did not influence the neurological outcome. One major and three minor complications occurred. All patients showed full recovery. The risk factors identified for vasoplegia include prolonged surgery with osteotomies. CONCLUSIONS: Vasoplegia is a rare condition with an incidence of .6%. Patients experiencing vasoplegia did not appear to experience worse surgical outcomes. The use of special intraoperative hemodynamic monitoring should be considered in selected cases.

A Retrospective Comparative Analysis of Perioperative Complications in Navigated versus Conventional Thoracolumbar Fusion in the Setting of Adult Spinal Deformity.

OBJECTIVE: Stereotactic intraoperative computer-assisted navigation has been shown to improve pedicle screw accuracy in spinal fusion surgery, but evidence of impact of navigation on clinical outcomes is lacking. The aim of this study is to compare rates of perioperative complications between navigated and nonnavigated procedures for deformity correction. METHODS: An administrative database was queried for adult patients undergoing thoracolumbar fusion procedures for deformity. Nonelective cases and those involving malignancy, infection, or trauma were excluded. Individuals were divided into 2 cohorts based on the use of stereotactic intraoperative navigation and paired 1:1 for comparison based on a propensity score matching algorithm. Rates of unplanned reoperation and other perioperative complications were compared between matched groups. A multivariable Cox regression model was constructed to identify the impact of navigation on specific subgroups. RESULTS: A total of 6150 patients met eligibility criteria for the study; after propensity score matching, 456 patients who underwent conventional fusion were matched to 456 patients receiving intraoperative navigation. Navigated cases took an average of 30 minutes longer than nonnavigated cases. There were no significant differences in rates of complications between cohorts. A subgroup analysis revealed that use of navigation was associated with decreased hazard for reoperation in individuals undergoing interbody fusion. CONCLUSIONS: Despite increased surgical duration, the use of navigation does not seem to significantly impact rates of perioperative complications outside of procedures involving interbody fusion. Surgeons should elect to use navigation in cases expected to be of high operative complexity at their own discretion.

Use of intraoperative MRI for resection of intracranial tumors: A nationwide analysis of short-term outcomes.

OBJECTIVE: Recent evidence supports the use of intraoperative MRI (iMRI) during resection of intracranial tumors due to its demonstrated efficacy and clinical benefit. Though many single-center investigations have been conducted, larger nationwide outcomes have yet to be characterized. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database to examine baseline characteristics and 30-day postoperative outcomes among patients undergoing craniotomy for tumor resection with and without iMRI. Comparisons between outcomes were accomplished after propensity matching using chi-square tests for categorical variables and Welch two-sample t-tests for continuous variables. RESULTS: A total of 38,003 patients met inclusion criteria. Of this population, 54 (0.1%) received iMRI, while 37,949 (99.9%) did not receive iMRI. After propensity score matching, the resulting groups consisted of an iMRI group (n = 54) and a matched non-iMRI group (n = 54). Procedures involving iMRI were associated with significantly increased operation length compared to those without (p < 0.01). Length of hospital stay was higher in patients without iMRI, with this difference trending towards significance (p = 0.05) in the unmatched comparison. Patients undergoing craniotomy without iMRI had a higher rate of readmission (p = 0.04). There was no significant difference in occurrence of other adverse events between the two patient groups. CONCLUSION: Despite increasing operative length, iMRI is not associated with higher infection rate and may have a clinical benefit associated with reducing readmissions and a trend towards reducing inpatient length of stay. Additional nationwide analyses including more iMRI patients would provide further insight into the strength of these findings.

Thrombocytopenia as an Independent Prognostic Indicator Following Extradural Spinal Tumor Resection.

OBJECTIVE: Few studies have examined the prognosis for patients with baseline thrombocytopenia undergoing extradural spine tumor resection. Our objective was to evaluate mortality, readmission, and other 30-day outcomes in patients with varying degrees of preoperative thrombocytopenia undergoing osseous extradural tumor excision. METHODS: A multicenter registry was queried for patients treated from 2011-2019. Patients were categorized according to baseline preoperative platelet count, in 25,000/µL increments: 125,000-149,000/µL, 100,000-125,000/µL, 75,000-100,000/µL, and <75,000/µL. These were compared to a control group with platelet count >150,000/µL. Outcomes in each cohort were analyzed using multivariate logistic regression analysis. RESULTS: The database search revealed 3574 patients undergoing extradural tumor resection; 2171 (60.7%) patients with platelets 125,000-149,000/µL, 114 (3.2%) with 100,000-125,000/µL, 43 (1.2%) with 75,000-100,000/µL, and 42 (1.2%) with <75,000/µL. Platelet counts <100,000/µL was associated with perioperative blood transfusion, cardiac complications, non-home discharge, and 30-day mortality. On subgroup analysis for mortality, an interaction was present between individuals with moderate/severe thrombocytopenia and cervical tumors. CONCLUSIONS: In patients undergoing surgery for extradural spine tumor, degree of baseline thrombocytopenia-rather than presence alone-is an independent predictor of several adverse events. Wherever possible, optimization of preoperative platelet count to at least 100,000/µL may improve outcomes.

The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systemic review and meta-analysis. OBJECTIVE: To review and establish the effect of tobacco smoking on risk of nonunion following spinal fusion. METHODS: A systematic search of Medline, Embase, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from inception to December 31, 2020, was conducted. Cohort studies directly comparing smokers with nonsmokers that provided the number of nonunions and fused segments were included. Following data extraction, the risk of bias was assessed using the Quality in Prognosis Studies Tool, and the strength of evidence for nonunion was evaluated using the GRADE working group criteria. All data analysis was performed in Review Manager 5, and a random effects model was used. RESULTS: Twenty studies assessing 3009 participants, which included 1117 (37%) smokers, met inclusion criteria. Pooled analysis found that smoking was associated with increased risk of nonunion compared to not smoking ≥1 year following spine surgery (RR 1.91, 95% CI 1.56 to 2.35). Smoking was significantly associated with increased nonunion in those receiving either allograft (RR 1.39, 95% CI 1.12 to 1.73) or autograft (RR 2.04, 95% CI 1.54 to 2.72). Both multilevel and single level fusions carried increased risk of nonunion in smokers (RR 2.30, 95% CI 1.64 to 3.23; RR 1.79, 95% CI 1.12 to 2.86, respectively). CONCLUSION: Smoking status carried a global risk of nonunion for spinal fusion procedures regardless of follow-up time, location, number of segments fused, or grafting material. Further comparative studies with robust methodology are necessary to establish treatment guidelines tailored to smokers.

Iliac Screw Fixation Revisited: Improved Clinical and Radiologic Outcomes Using a Modified Iliac Screw Fixation Technique.

STUDY DESIGN: A retrospective study. OBJECTIVE: To describe the modified iliac screw (mILS) technique and compare it to other spinopelvic fixation techniques in terms of wound healing complications, hardware prominence, and failure. SUMMARY OF BACKGROUND DATA: The traditional entry point of an iliac screw often causes postoperative gluteal pain from the prominent screw head. The use of an offset connector also adds a point of weakness to the construct. By choosing a different screw entry point offset connectors can be avoided, and the screw head itself is less prominent, thereby reducing postoperative discomfort. MATERIALS AND METHODS: A retrospective analysis was performed of adult patients undergoing lumbopelvic fixation (LPF) between January 2014 and June 2019. Patients were grouped into 1 of 3 groups based on the technique of pelvic fixation: S2 alar-iliac (S2AI) screw, traditional iliac screw (tILS), and mILS. The primary outcome parameter was the minimal distance from screw head to skin. Secondary outcome parameters were instrumentation loosening/failure, adjacent level fractures, pseudoarthrosis, and medial or lateral iliac screw perforation. RESULTS: A total of 190 patients undergoing LPF were included in the following 3 groups: mILS group (n=113), tILS group (n=40), and S2AI group (n=37). The mean minimal distance from screw head to skin in the mILS group was 31.3 mm compared with 23.7 mm in the tILS group (P<0.00199). No statistically significant differences were found when comparing the 3 groups with respect to complications. The mILS group did not show any cases of prominent instrumentation and had the lowest rate of instrumentation failure. CONCLUSIONS: The mILS technique is an acceptable alternative for LPF, offering the benefits of iliac screw fixation while avoiding offset connectors and screw prominence complications associated with tILS. LEVEL OF EVIDENCE: Level III.

A novel anatomo-physiologic high-grade spondylolisthesis model to evaluate L5 nerve stretch injury after spondylolisthesis reduction.

L5 nerve palsy is a well-known complication following reduction of high-grade spondylolisthesis. While several mechanisms for its occurrence have been proposed, the hypothesis of L5 nerve root strain or displacement secondary to mechanical reduction remains poorly studied. The aim of this cadaveric study is to determine changes in morphologic parameters of the L5 nerve root during simulated intraoperative reduction of high-grade spondylolisthesis. A standard posterior approach to the lumbosacral junction was performed in eight fresh-frozen cadavers with lumbosacral or lumbopelvic screw fixation. Wide decompressions of the spinal canal and L5 nerve roots with complete facetectomies were accomplished with full exposure of the L5 nerve roots. A 100% translational slip was provoked by release of the iliolumbar ligaments and cutting the disc with the attached anterior longitudinal ligament. To evaluate the path of the L5 nerves during reduction maneuvers, metal bars were inserted bilaterally at the inferomedial aspects of the L5 pedicle at a distance of 10 mm from the midpoint of the L5 pedicle screws. There was no measurable change in length of the L5 nerve roots after 50% and 100% reduction of spondylolisthesis. Mechanical strain or displacement during reduction is an unlikely cause of L5 nerve root injury. Further anatomical or physiological studies are necessary to explore alternative mechanisms of L5 nerve palsy in the setting of high-grade spondylolisthesis correction, and surgeons should favor extensive surgical decompression of the L5 nerve roots when feasible.

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty.

BACKGROUND: Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay. METHODS: A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days. RESULTS: A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking. CONCLUSIONS: Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

Pathognomonic macular ripples are revealed by polarized infrared retinal imaging.

A pathognomonic macular ripple sign has been reported with scanning laser ophthalmoscopy images in patients with foveal hypoplasia, though the optical basis of this sign is presently unknown. Here we present a case series of seven individuals with foveal hypoplasia (based on spectral domain optical coherence tomography). Each patient underwent infrared scanning laser ophthalmoscopy retinal imaging in both eyes, acquired with and without a polarization filter and assessment for a ripple-like effect in the fovea. On imaging, macular ripples were present in all eyes with foveal hypoplasia when using a polarization filter, but not when imaged without the filter. We conclude that the macular ripple sign is an imaging artifact attributable to the unique pattern of phase retardation of the Henle fiber layer in the setting of foveal hypoplasia. By utilizing a polarization filter with retinal photography, this feature can be exploited to promptly identify foveal hypoplasia in settings where OCT is not possible due to nystagmus.

Surgical Management of Charcot Spinal Arthropathy in the Face of Possible Infection.

BACKGROUND: The design is a retrospective cohort study. Charcot spinal arthropathy (CSA) is a rare and poorly understood progressive destructive spine condition that usually affects patients with preexisting spinal cord injury. The complexity of this condition, especially when additionally burdened by superimposed infection in the CSA zone, can potentially lead to suboptimal management such as protracted antibiotic therapy, predisposition to hardware failure, and pseudarthrosis. While in noninfected CSA primary stabilization is the major goal, staged surgical management has not been stratified based upon presence of a superinfected CSA. We compare clinical and radiological outcomes of surgical treatment in CSA patients with and without concurrent spinal infections. METHODS: Our single-institution database was reviewed for all patients diagnosed with CSA and surgically treated, who were subsequently divided into 2 cohorts: spinal arthropathy with superimposed infection and those without. Those were comparatively studied for complications and reoperation rate. RESULTS: Fifteen patients with CSA underwent surgical intervention; mean follow up of 15.3 months (range, 0-43). Eleven patients received stabilization with a quadruple-rod thoracolumbopelvic construct, while 4 patients with superinfected CSA underwent a staged procedure. Patients treated with a staged approach experienced fewer intraoperative complications (0% versus 18%) and fewer revision surgeries (25% versus 36%). Both cohorts had the same eventual healing. CONCLUSIONS: Surgical management in CSA patients with primary emphasis on stability and modified surgical treatment based on presence of an active infection in the zone of neuropathic destruction will lead to similar eventual successful results with relatively few and manageable complications in this challenging patient population. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: The proposed treatment algorithm including the use of a quadruple-rod construct with lumbopelivic fixation and a staged approach in patients with superinfected CSA represents a reasonable option in the surgical treatment of CSA.

Outcomes and Patterns of Care in Adult Skull Base Chondrosarcoma Patients in the United States.

BACKGROUND: Chondrosarcomas of the skull base are rare intracranial tumors of chondroid origin. The rarity of these lesions has made it difficult to form a consensus on optimal treatment regimens. The aim of this study was to provide a comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with chondrosarcoma of the skull base. METHODS: Patients with diagnosis codes for chondrosarcoma of the skull base were queried from the National Cancer Database for the years 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS: A total of 718 patients with chondrosarcoma of the skull base were identified. Mean overall survival (OS) in these patients was 10.7 years. Older age and presence of metastases were associated with worsened OS. Of patients, 83.3% received surgical intervention, and both partial resection and radical resection were associated with significantly improved OS (P < 0.001). Neither radiotherapy nor chemotherapy improved OS; however, patients who received proton-based radiation and patients who received high-dose radiation (≥6000 cGy) had significantly improved OS compared with patients who received traditional radiation. CONCLUSIONS: In the largest study to our knowledge of skull base chondrosarcoma to date, both partial resection and radical resection significantly improved OS, thus supporting the goal of maximal safe resection to preserve vital neurovascular structures without sacrificing outcome. In patients who received radiotherapy, proton-based modalities and high-dose radiation were associated with increased OS.

Assessing the Clinical Safety Profile of Computer-Assisted Navigation for Posterior Cervical Fusion: A Propensity-Matched Analysis of 30-Day Outcomes.

BACKGROUND: Computer-assisted navigation (CAN) has been shown to improve accuracy of screw placement in procedures involving the posterior cervical spine, but whether the addition of CAN affects complication rates, neurologic or otherwise, is presently unknown. The objective of this study is to determine the effect of spinal CAN on short-term clinical outcomes following posterior cervical fusion. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2018. Patients receiving posterior cervical fusion were identified and separated into CAN and non-CAN cohorts on the basis of a propensity score matching algorithm to select similar patients for comparison. Rates of 30-day unplanned readmission, reoperation, and other complications were evaluated. A separate matching algorithm was used to generate a subgroup of patients undergoing C1-C2 or occiput-C2 fusion for comparison of the same outcomes. RESULTS: A total of 12,578 patients met inclusion criteria, of which 689 received CAN and 11,889 did not. After adjusting for baseline differences, patients receiving CAN experienced longer operations and had higher total relative value units associated with care. There were no significant differences in 30-day complication, readmission, or revision rates. At the occipitocervical junction, there were more hardware revisions in the non-CAN group, but this effect did not reach statistical significance (2 vs. 0; P = 0.155). CONCLUSIONS: Surgeons should embrace navigation in the cervical spine at their own discretion, as use of CAN does not appear to be associated with increased rates of surgical complications or readmissions despite longer operative time.

Incidence, Management, and Outcomes of Adult Patients with Spinal Chondrosarcoma in the United States.

OBJECTIVE: Spinal chondrosarcomas are rare primary malignant neoplasms composed of cartilage-producing cells. They are slow-growing but locally aggressive lesions that have high rates of recurrence and progression after treatment. We provide the largest comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with spinal chondrosarcoma using a large, prospectively collected national database. METHODS: Patients with diagnosis codes specific for chondrosarcoma of the spine, sacrum, and coccyx were queried from the National Cancer Database (NCDB) during 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS: A total of 1843 individuals were identified with a diagnosis of chondrosarcoma, 82.1% of which were at the sacrum or coccyx and 17.9% at the spine. The mean overall survival of patients in our cohort was 7.91 years. Increased age, larger tumor, dedifferentiated histology, and presence of metastases were associated with worsened overall survival. Regarding management, 77.7% of patients received surgical intervention and both partial and radical resection were associated with significantly improved overall survival (P < 0.001). Neither radiotherapy nor chemotherapy administration improved overall survival; however, among patients who received radiation, those who received higher-dose radiation had significantly improved overall survival compared with those who received lower-dose radiation. CONCLUSIONS: Surgical resection significantly improves overall survival in patients with spinal chondrosarcoma. In those patients receiving radiation, those who receive high doses have improved overall survival compared with those who receive lower doses. Further studies into optimal radiation modality and doses are required.

High-Grade Spinal Hemangioma: A National Cancer Database Analysis.

BACKGROUND: Spinal hemangiomas are common primary tumors of the vertebrae. Although these tumors are most frequently benign and asymptomatic, they can rarely exhibit aggressive growth and invasion into neighboring structures. Treatment for these aggressive variants is controversial, often involving surgery, chemotherapy, and/or radiotherapy. This study sought to investigate current trends affecting overall survival (OS) using the National Cancer Database (NCDB) and to formulate treatment recommendations. METHODS: The National Cancer Database was queried for spinal hemangiomas between 2004 and 2016. A Cox proportional hazards model was used to perform multivariate regression analysis of survival. Survival curves for comparative visualization of demographic and treatment factors were generated using a semiparametric Cox approach. RESULTS: A cohort of 102 patients with histologically confirmed spinal hemangiomas was identified in the database. Mean OS was 1.94 years. Administered treatments included partial surgical resection (n = 17), radical resection (n = 14), chemotherapy (n = 34), and radiotherapy (n = 56). Multivariate analysis revealed associations between decreased OS and advanced age (>65 years) and presence of metastasis. Cox survival analysis further revealed improved OS in patients who received surgical treatment and higher radiation dose. CONCLUSIONS: This retrospective analysis finding that treatment with surgical resection and/or radiotherapy is associated with increased OS constitutes the largest cohort of patients with aggressive vertebral hemangiomas to date. Given that the mean OS of the study cohort was 1.94 years, our findings suggest that the optimal treatment regimen to maximize survival should consist of early surgical resection with adjuvant high-dose radiotherapy.

Incidence, Management, and Outcomes of Spinal Giant Cell Tumor of Bone in Adult Patients: A National Cancer Database Analysis.

OBJECTIVE: Giant cell tumors (GCTs) constitute 5% of all primary bone tumors with spinal GCTs (SGCTs) accounting for 2%-15% of all GCTs. The standard of care for SGCT has been maximal surgical resection. However, many adjuvant therapies have been used owing to the difficulty in achieving gross total resection combined with the high local recurrence rate. The purpose of the present study was to analyze the incidence, management, and outcomes of SGCT. METHODS: Patients with diagnosis codes specific for SGCT were queried from the National Cancer Database from 2004 to 2016. The outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS: The search criteria identified 92 patients in the NCDB dataset from 2004 to 2016 with a diagnosis of SGCT. Of the 92 patients, 64.1% had undergone surgical intervention, 24.8% had received radiotherapy, and 15.2% had received immunotherapy. Univariate analysis revealed that age ≥55 years and tumor location in the sacrum/coccyx were associated with worsened overall survival (OS) and that surgical resection was associated with improved OS. On multivariate analysis, age 55-64 years was associated with worsened OS, and radical surgical resection was associated with improved OS. The survival analysis revealed improved OS with surgery but not with radiotherapy, chemotherapy, or immunotherapy. CONCLUSION: SGCT is a rare primary bone tumor of the vertebral column. The standard of care has been surgical resection with the goal of gross total resection; however, adjuvant therapies have often been used. Our study found that surgical resection significantly improved OS and that immunotherapy neared significance in improving OS.