Separation Surgery, Fixation With Carbon-Fiber Implants, and Stereotactic Body Radiotherapy for Oligometastatic Spinal Disease.

The management of spinal metastases focuses on reducing symptoms and protecting the spinal cord, historically involving extracorporeal radiotherapy alone. The use of separation surgery techniques alongside high-dose radiotherapy to treat spinal metastases is a novel concept and has changed the treatment paradigm. Additionally, titanium implants have been increasingly used in cases of metastatic spinal tumours requiring adjuvant stereotactic radiotherapy (SBRT). We present the case of a 48-year-old female patient who was diagnosed with a metastatic deposit of breast cancer within L1 with an Epidural Spinal Cord Compression score greater than 1a. At the time of the diagnosis, her prognosis was estimated to be more than two years. She underwent a posterior instrumented fusion of T11-L3 vertebrae with a carbon-fibre fixation system and separation surgery (debulking of the tumour around the spinal cord). The patient was discharged on the second postoperative day achieving complete resolution of the mechanical back pain. SBRT was performed 12 weeks after the surgery. The patient regained ECOG status of 1 shortly after but sadly passed away due to multiple brain metastases 36 months following posterior fixation. Her spinal disease remained well-controlled throughout the follow-up. Carbon-fibre implants appear to be safe and relatively easy to apply. Their use, due to limited artefacts in both computed tomography and magnetic resonance imaging, makes SBRT much more straightforward and follow-up imaging easier to be interpreted. Our experience demonstrates that, in conjunction with separation surgery, the translucent, low perturbing properties of these implants can improve SBRT intervention and detection of recurrence on follow-up imaging.

Spinal Tumour en Bloc Surgery: A Series of Abandoned Surgical Cases.

Select spinal tumors can be treated with en bloc spondylectomy (EBS) but the surgical complexity and relatively low frequency of eligible tumors render EBS an uncommon procedure. The expanded surgical access encompasses acceptance of relatively high morbidity as a trade-off against improved oncological results and survival. EBS durations can be long with dynamic changes affecting the risk-benefit ratio as the surgery proceeds.  We present a series of cases where we have elected to "abandon" EBS due to adverse findings or rising intraoperative risk along with our lessons learned.  A search of our surgical database for all "en bloc" spinal tumor procedures over a three-year period was performed and 27 operations were identified. Of these, four were abandoned. Two of the four surgeries were halted owing to adverse anatomical findings. One involved significant tumor growth from the interval imaging bringing into question disease control and the other displayed tumor adherence to the lung requiring significant dissection. The further two cases incurred significant blood loss and associated physiological complications of end-organ dysfunction.  Pre-operative embolization (POE), anesthetic monitoring, controlled hypotension, volume replacement, and transfusion optimize our chance of achieving the surgical plan. However, cardiovascular instability must be managed promptly and early warning signs of end-organ injury (lactate, renal output) should not be overlooked. In some situations abandoning the procedure may be in the best interests of the patient.

Factors Influencing Surgical Outcomes for Intradural Spinal Tumours: A Single-Centre Retrospective Cohort Study.

Introduction Intradural spinal tumours are relatively uncommon tumours of the central nervous system. In this study, we sought to assess our current practice and determine the factors which affect the surgical outcomes of intradural spinal tumour resection. Methods All consecutive patients who underwent surgical resection of intradural spinal tumours from December 2011 to November 2018 were retrospectively reviewed. The Modified McCormick Scale (MMS) was used to grade patients' neurological status both pre-operatively and at the latest follow-up. The associations between changes in MMS and variables such as patient demographics, tumour location, number and experience of consultants involved in the procedure, use of intraoperative neuro-monitoring, bony spinal exposure and dural closure methods were assessed. A multivariable binary logistic regression model was performed to identify independent predictors of improvements in MMS. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p<0.05 deemed to be indicative of statistical significance throughout. Results A total of 145 patients met the inclusion criteria, with a median age of 56.5 years; of whom 119 had extramedullary tumours and 26 had intramedullary tumours. Methods of dural closure were variable, and there was an increasing trend over time towards using the laminoplasty approach for bony exposure. Neither the experience of consultants (p=0.991) nor the number of consultants involved (p=0.084) was found to be significantly associated with the change in MMS, with the strongest predictor being the baseline MMS (p<0.001). Patients who had adjuvant therapy were also significantly more likely to have a poorer neurological outcome (p=0.001). Conclusion A good neurological baseline is a significant positive predictor of an improved functional outcome. The number and seniority of consultant surgeons involved in intradural spinal tumour resections did not significantly alter the postoperative outcomes of patients in our single-unit retrospective study.

Serum biomarkers and cerebral autoregulation as early warnings of delayed cerebral ischemia risk in patients after aneurysmal subarachnoid haemorrhage.

BACKGROUND: Identifying patients at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) remains challenging. This study aimed to evaluate the concentration of serum biomarkers along with cerebral autoregulation impairment on DCI. METHODS: 55 patients suffering from aSAH were enrolled in the study. Serum S100protein B (S100B) was tested both on the day of admission and over three consecutive days following the occurrence of aSAH. Cerebral autoregulation was assessed using a tissue oxygenation index (TOxa) based on near-infrared spectroscopy. RESULTS: Changes in serum S100B levels interacted with DCI status (presence vs. absence): F = 3.84, p = 0.016. Patients with DCI had higher S100B concentration level on day 3 than those without DCI (3.54 ± 0.50 ng/ml vs. 0.58 ± 0.43 ng/ml, p = 0.001). S100B concentration on day 3 following aSAH predicted DCI (AUC = 0.77, p = 0.006). Raised level of serum S100B on day 3 was related with higher TOxa, thus with impaired cerebral autoregulation (rS = 0.52,p = 0.031). Multivariate logistic regression analysis showed thatimpaired cerebral autoregulation andelevatedS100B concentration on day 3 increasethe likelihood of DCI. CONCLUSIONS: Tracking changes in the serum biomarkers concentration along with monitoring of cerebral autoregulation, may play a role in early detection of patients at risk of DCI after aSAH. These results need to be validated in larger prospective cohorts.

En Bloc Resection of Tumors of the Lumbar Spine: A Systematic Review of Outcomes and Complications.

BACKGROUND: The literature on total en bloc spondylectomy (TES) of bone tumors of the lumbar spine is sparse and heterogeneous. Therefore, the aim was to systematically pool the data from the published studies to quantitatively summarize the morbidity and mortality and to identify factors associated with favorable outcomes and complications. METHOD: A systematic literature search for studies with individual patient-level data was conducted using specific medical subject heading(MeSH) terms. The outcome measures assessed included complications, tumor recurrence, survival, and function. Individual patient data were pooled from all the studies and quantitatively analyzed to assess the association of different factors with outcomes and complications. RESULTS: Twelve studies were included in this review with a total of 145 TES cases. Of all patients, 50% had at least 1 reported complication post surgery and this was associated with advancing age (OR 1.04, P < 0.001), metastatic disease (OR 5.61, P < 0.001), and adjuvant chemo and/or radiotherapy (OR 20.3, P = 0.001). Intralesional excision (OR 5.2, P = 0.01) and primary malignant tumors (OR 3.3, P = 0.02) were associated with a high recurrence rate. However, the surgical approach was not associated with differences in survival (P = 0.874) or recurrence (P = 0.525) rates. L5 tumor resection was associated with excessive bleeding. Postoperatively, there was an overall improvement in the Frankel grades in most patients. CONCLUSION: TES is associated with high rates of complications especially in association with primary malignant and metastatic diseases. However, the number of publications on this topic remain scarce and heterogeneous. Hence, there is a need for standardization in the reporting of the outcomes and complications to help with decision-making and consenting for this procedure.

Should Denosumab or Radical Surgery Be Recommended for a Spinal Giant Cell Tumour in a Fertile Female?

Giant cell tumour (GCT) of the spine is a benign aggressive tumour with high recurrence rates. Patients can be asymptomatic due to the slow growth rate and present with localized pain or neurological dysfunction. Current management strategies include intralesional curettage, total en-bloc resection (TER) and denosumab therapy. Treatment strategies can be particularly challenging in women of childbearing age who wish to conceive, as the risks of tumour recurrence need to be balanced against the fetal complications associated with adjuvant denosumab therapy. This case report discusses the management options and controversies for women of childbearing age with GCT of the thoracic spine. Clinicians need to be aware of the complications associated with TER and denosumab treatment when managing GCTs of the spine in young females.

An interdisciplinary approach to the management of critically ill patients during covid-19 pandemic; an experience of a university hospital in England.

COVID-19 pandemic presents significant challenges in delivering safe and efficient patient care, especially during the surges. In all health care systems, provision of available critical care facilities is a scarce resource, even in normal times. Problematic is not just the limitation of physical spaces in intensive care units, but also the availability of trained personnel. The critical care model, developed in Queen Elizabeth Hospital Birmingham to cope with the surge of COVID-19 patients, is based on early implementation of an interdisciplinary approach and extensive cooperation between the branches of practice, allowing to address both challenges. The main pillars are early upskilling of non-critical care staff, creation of safe, streamlined clinical pathways, adjustment of the physical layout of critical care units and comprehensive cross-town cooperation allowing to accommodate an increased number of patients, requiring intensive care. The model was well tested in clinical practice, enabling the hospital to increase the critical care footprint by more than 200% during the pandemic's surge between March and May 2020.

Metastatic Pituitary Carcinoma Causing Cord Compression.

A 39-year-old man with a history of recurrent pituitary tumor, Cushing disease, and Nelson syndrome presented with neck stiffness. He previously had bilateral adrenalectomy and hypophysectomy 27 years ago. He subsequently had repeat pituitary surgery, stereotactic radiosurgery, and chemotherapy for recurrent pituitary tumor. During follow-up, he was noted to have rising basal adrenocorticotrophin (ACTH) level. On examination, he was neurologically intact with no signs of myelopathy. Magnetic resonance imaging of the spine showed a large intradural extramedullary lesion causing cord compression at the C2-3 level. He underwent a cervical laminectomy and debulking of the lesion under continuous monitoring of motor-evoked and somatosensory-evoked potentials. He remained neurologically intact postoperatively. Histologic analysis revealed a tumor of pituitary origin with synaptophysin and ACTH expression. Pituitary drop metastasis is a rare entity and should raise a high index of suspicion given this clinical presentation. The radiologic appearance can mimic benign lesions such as meningioma or schwannoma.

Navigated neuroendoscopy combined with intraoperative magnetic resonance cysternography for treatment of arachnoid cysts.

Endoscopic cystocysternostomy or cystoventriculostomy is the treatment of choice in patients with symptomatic intracranial arachnoid cysts. There are no objective diagnostic tests for reliable intraoperative evaluation of the effectiveness of performed stomies. The aim of this prospective open-label study is to demonstrate for the first time the usefulness of intraoperative cysternography performed with the low-field 0.15-T magnetic resonance imager Polestar N20 during endoscopic cysternostomies. The study was performed in patients operated for middle fossa arachnoid cysts (n = 10), suprasellar cysts (n = 4), paraventricular or intraventricular cysts (n = 6), and a pineal cyst (n = 1). The operations were performed with use of a navigated neuroendoscope. Intraoperative magnetic resonance (iMR) cysternography was performed before and after the cystostomy. In each case, iMR cysternography was safe and could show clearly the cyst morphology and the effectiveness of performed endoscopic cystostomies. In six cases, iMR cysternography had a significant influence of the surgical decision (p = 0.027). The rate of inconsistency between the intraoperative observations and iMR imaging-based findings was 29%. A good contrast flow through the fenestrated cyst walls correlated with a good long-term clinical outcome (ρ = 0.54, p < 0.05) and good long-term radiological outcome (ρ = 0.72, p < 0.05). Intraoperative low-field MR cysternography is a safe and reliable method for assessment of the efficacy of performed endoscopic cystostomies and has significant influence on the surgical decision. It may be reliably used for prediction of the long-term clinical and radiological outcome.

Tumours of the odontoid peg revisited.

INTRODUCTION: Tumours of the odontoid peg are rare but can potentially cause significant morbidity and mortality. METHODS: A retrospective review of oncology and radiology database of tertiary orthopaedic oncology centre for all lesions affecting the odontoid peg over the last 12 years was performed. RESULTS: We identified a total of 15 tumours involving the odontoid peg, majority being malignant. Myeloma was the most common tumour. CONCLUSION: Tumours of the odontoid peg are rare. Spinal surgeons and Radiologists need to be aware of them.

The denticulate ligament - Tensile characterisation and finite element micro-scale model of the structure stabilising spinal cord.

BACKGROUND: Damage to the spinal cord is one of the most debilitating pathologies with considerable health, economic and social impact. Improved prevention, treatment and rehabilitation after spinal cord injury (SCI) requires the complex biomechanics of the spinal cord with all its structural elements and the injury mechanism to be understood. This comprehensive understanding will also allow development of models and tools enabling better diagnosis, surgical treatment with increased safety and efficacy and possible development of regenerative therapies. The denticulate ligaments play an important role in stabilising spinal cord within the spinal canal. They participate in spinal cord movements and play a role in determining the stress distribution during physiological but also traumatic loading. We present detailed tensile characterisation of the denticulate ligaments and a Finite Element micro-scale model of the ligament relating its structure with the distribution of stress under physiological loading. METHOD: Denticulate ligaments were dissected from cervical spinal levels from 6 porcine cervical specimens with fragments of the pia and dura mater and characterised in terms of their geometry and response to uniaxial tensile loading. The stress-strain characteristics were recorded until rupture of the ligament, ultimate parameters and Young's moduli were determined. The parametric micro-structural Finite Element model was constructed based on literature microscope and histological images of a denticulate ligament as a phenomenological representation of the complex microstructure of a soft tissue. The model was validated against the experimental data. RESULTS: Stress-strain characteristics obtained in tensile test were typical for a soft tissue behaviour. No statistically relevant differences in ultimate strength, strain and Young's moduli were observed between the ligaments harvested from different vertebral levels. Average ultimate tensile stress was 1.26 ±â€¯0.20 MPa at strain 0.51 ±â€¯0.00, rupturing force (1.01 ±â€¯0.21 N) was in agreement with results obtained previously. The Finite Element model accurately predicted the extension-load behaviour of the denticulate ligament in elastic regime. The micro-scale structural representation enabled capturing deformation modes representative of the experimentally observed behaviour. CONCLUSIONS: The presented stress-strain characteristics of the denticulate ligaments add valuable data to the understanding of the biomechanics of the spinal cord and enable development of more accurate models. The developed micro-scale model was capable of capturing biomechanical response of collagenous tissue under tensile loading, it can be applied for the prediction of other soft tissues behaviours. The denticulate ligament model should be included into future spinal cord models to fully represent the complex system's biomechanics and enable development of surgical aid tools to improve patient outcomes and future regenerative therapies.

Plant lyophilisate carrying S-HBsAg as an oral booster vaccine against HBV.

A formulation of a defined antigen dosage together with an appropriate and convenient immunisation regime are the main problems of a plant-derived oral vaccine against HBV. Both factors have to be mutually adjusted to ensure efficacious vaccination and to minimise the risk of oral tolerance acquisition. As based on previous research, solely oral immunisation appears to be of limited effectiveness, but a combined immunisation scheme via injection priming and oral boosting can be proposed. Thus, the previously optimised plant lyophilisate with accumulated S-HBsAg was orally administered in a series of mouse immunisation trials. The impact of various S-HBsAg oral dosages and concentrations on the induction of an active immune response was studied. Immunisation via i.m. priming followed by double oral boosting in 6-week intervals was comparably efficient as standard i.m. vaccination. Among the tested dosages, 2× 5 or 200 ng triggered effective and exclusively systemic responses. Mucosal adjuvants CTB or quillaja bark saponins as well as alhydrogel either had no or a negative effect on immune response, which indicates that a low-dosed plant lyophilisate as an oral booster vaccine may not require exogenous adjuvants. Additionally, a positive effect of S-HBsAg encapsulation in lyophilised cells on immune response stimulation was confirmed by comparison with the antigen released in the plant extract. The low-dosed plant lyophilisate with concentrated S-HBsAg was proven as an effective and convenient oral booster vaccine. Results of immunisation via a mixed injection-oral route provide the foundation for research on further standardisation of a plant-derived oral vaccine against HBV and details of immune response together with effects for health condition.

Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study.

BACKGROUND CONTEXT: Odontoid process fractures are the most common injuries of the cervical spine in the elderly. Anterior screw stabilization of type II odontoid process fractures improves survival and function in these patients but may be complicated by failure of fixation. PURPOSE: The present study aimed to determine whether cement augmentation of a standard anterior screw provides biomechanically superior fixation of type II odontoid fractures in comparison with a non-cemented standard screw. STUDY DESIGN: Twenty human cadaveric C2 vertebrae from elderly donors (mean age 83 years) were obtained. METHODS: Anderson and D'Alonzo type IIa odontoid fracture was created by transverse osteotomy, and fluoroscopy-guided anterior screw fixation was performed. The specimens were divided into two matched groups. The cemented group (n=10) had radiopaque high viscosity polymethylmethacrylate cement injected via Jamshidi needle into the base of the odontoid process. The other group was not augmented. A V-shaped punch was used for loading the odontoid in an anteroposterior direction until failure. The failure state was defined as screw cutout or 5% force decrease. Mean failure load and bending stiffness were calculated. RESULTS: The mean failure load for the cemented group was 352±12 N compared with 168±23 N for the non-cemented group (p<.001). The mean initial stiffness of the non-cemented group was 153±19 N/mm compared with 195±29 N/mm for the cemented group (p<.001) CONCLUSIONS: Cement augmentation of an anterior standard screw fixation of type II odontoid process fractures in elderly patients significantly increased load to failure under anteroposterior load in comparison with non-augmented fixation. This may be a valuable technique to reduce failure of fixation.

Oblique corpectomy in the cervical spine.

STUDY DESIGN: A narrative review. OBJECTIVES: A literature review of studies reporting on the application of oblique corpectomy (OC) in various pathologies of the cervical spine. SETTING: UK. METHODS: A search was carried out using the PubMed and Google Scholar up to 18 March 2017. Finally, 26 studies met the inclusion criteria. RESULTS: A multilevel OC shows good clinical outcomes in various pathologies in the cervical spine. The clinical improvement in cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament was found to be over 70%. OC allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression. The approach carries a risk of Horner's syndrome, vertebral artery and accessory nerve injury. OC does not compromise spine stability and osteoarthrodesis with bone grafting is not necessary. Spinal motions are preserved and appear close to normal. OC can be applied in patients with a low fusion rate such as the elderly, diabetics, and heavy smokers. Furthermore, OC was found to be an optimal approach for exta-intradural tumors of the cervical spine. CONCLUSIONS: OC seems to be a valid alternative for the management of multisegmental CSM in selected cases. It should not be considered a first-line treatment strategy due to the relatively high morbidity. There are no studies comparing OC without fusion to other treatment options in CSM. Therefore, rigorous prospective studies using validated outcome measures with long-term follow-up are required.

HBcAg produced in transgenic tobacco triggers Th1 and Th2 response when intramuscularly delivered.

Hepatitis B core Antigen (HBcAg) assembled into Capsid-Like Particles (CLPs) is investigated as a therapeutic vaccine in treatment of chronic hepatitis B (CHB) and in diagnostic tests or as a carrier for various epitopes. While the expression of HBcAg has been thoroughly clarified in E. coli and yeast, it has also been investigated in other expression systems. Stably transformed tobacco expressed HBcAg at a level of 110-250µg/g fresh weight, therefore in view of its large leaf biomass it offers a production platform comparable with transient expression systems regarding the final yield of HBcAg. Several extraction and purification methods were tested and finally the antigen was purified up to 43% using sucrose density gradient centrifugation. The purified HBcAg retained its antigenicity, as confirmed by ELISA and western blot, while maintaining its CLP-structure as observed in TEM. In mice HBcAg intramuscularly delivered at 2×10µg triggered a significant response (serum anti-HBc titre around 150,000), being statistically equivalent to that induced by the reference antigen. Among anti-HBc IgG isotypes, IgG2a and then IgG1 were increasing during immune response. However IgG2b and IgG3 were also induced, especially in mice immunised with the plant-derived antigen. Analysis of the isotype profile indicates mainly Th1 polarisation, but completed with Th2 response. Obtained results indicate a considerable potential of plant-derived HBcAg as a therapeutic vaccine, since a mixed immune response with a stronger Th1 component is particularly required for treatment of CHB.

New method for correction of lumbo-sacral kyphosis deformity in patient with high pelvic incidence.

STUDY DESIGN: Technical note. OBJECTIVE: We describe a novel technique of bilateral longitudinal sacral osteotomy allowing direct reduction of high pelvic incidence (PI) and correction of sagittal imbalance. METHODS: A 25-year-old female patient presented with a disabling lumbo-sacral kyphosis fused in situ through previous operations with residual low-grade wound infection and grade IV L5/S1 spondylolisthesis with severity index (SI) of 65%. A two-stage correction was performed. First anterior in situ fixation of the L4-L5-S1 segments was performed using a hollow modular anchorages (HMA) screw and L3/L4 anterior interbody cage. The second stage consisted of instrumentation of the lower lumbar spine and pelvis; placement of an S1 transverse K-wire as pivot point and bilateral longitudinal sacral osteotomy which allowed for gradual retroversion of the central sacrum relative to the pelvis. RESULTS: Sacrum was derotated by 30° which allowed to restore spinal sagittal balance and decrease SI by 15%. Postoperative recovery was complicated by a flare up of the pre-existing deep wound infection. CONCLUSIONS: Bilateral longitudinal sacral osteotomy appears to be a safe and efficient way of correcting the sagittal imbalance caused by an extremely high PI. Although technically demanding, it achieves good radiological and functional outcomes and avoids entering the spinal canal.

Intraspinal Pressure Monitoring and Extensive Duroplasty in the Acute Phase of Traumatic Spinal Cord Injury: A Systematic Review.

OBJECTIVE: The prognosis in cervical spinal cord injury is poor, and surgical and neurointensive care management need further improvement. Monitoring of the intraspinal pressure (ISP) at an early stage after traumatic spinal cord injury (tSCI) is useful clinically. MATERIALS AND METHODS: Obtaining continuous spinal cord perfusion pressure (SCPP) measurements based on the difference between mean arterial pressure and ISP allows offering best medical and surgical treatment during this critical phase of tSCI. A search was carried out with PubMed, Embase, and Google Scholar up to January 10, 2017. Articles resulting from these searches and relevant references cited in those articles were reviewed. RESULTS: The optimal SCPP was found to be between 90 and 100 mm Hg and mean arterial pressure of 110-130. Laminectomy alone was found to be ineffective in the reduction of ISP because it does not lower the pressure exerted by dura on the swollen spinal cord. Therefore, bony decompression with durotomy or duroplasty seems to be the procedure of choice to reduce the ISP less than 20 mm Hg. CONCLUSIONS: A randomized controlled trial is required to determine whether laminectomy with durotomy and monitoring of ISP with SCPP optimization improve neurological recovery after tSCI.

Comparison of the timing of intervention and treatment modality of poor-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVES: The timing and modality of intervention in the treatment of poor-grade aneurysmal subarachnoid haemorrhage (aSAH) has not been defined. The purpose of the study is to analyse whether early treatment and type of intervention influence the clinical outcomes of poor-grade aSAH patients. MATERIAL AND METHODS: Patients with poor-grade aSAH were retrieved. Demographics, Fisher grade, radiological characteristics and clinical outcomes were recorded. Outcomes were compared using the modified Rankin Scale (mRS), for groups treated early within 24 hours of aSAH or later and by clipping or endovascular therapy. Multivariate multiple regression model and logistic regression were used to assess factors affecting outcomes at discharge in mRS and length of stay. RESULTS: The study was conducted on 79 patients. 47 (59%) were treated by clipping, 38 (48%) received intervention within 24 hours of aSAH. Patients treated <24h had significantly lower mortality (n = 5; 13% vs. n = 14; 37%; p < .023), higher rate of 0-3 mRS (n = 22;58% vs. n = 9; 22%; p < .039) and were younger (49.5 ± 6.1 vs. 65.8 ± 7.4 years; p < .038). There were no significant differences in mRS between clipping and endovascular therapy. Predictors of length of stay were ICH, MLS, endovascular therapy, location in posterior circulation, Fisher grade and time to intervention <24h. Early intervention, <24h significantly influenced the favourable results in mRS (0-3); (OR 4,14; Cl95% 3.82-4.35). Posterior circulation aneurysms, midline shift and intracerebral hematoma were correlated with poor outcomes. CONCLUSIONS: Early treatment, within 24 h, of poor-grade aSAH confirmed better clinical outcome compared to later aneurysm securement. There was no significant difference between clipping and endovascular treatment.

The computed tomography-based fractal analysis of trabecular bone structure may help in detecting decreased quality of bone before urgent spinal procedures.

BACKGROUND CONTEXT: To date, no reliable method is available to determine the parameters of bone density based on the routine spinal computed tomography (CT) in the emergency setup. We propose the use of fractal analysis to detect patients with poor quality of bone before urgent or semi-urgent spinal procedures. PURPOSE: This study aimed to validate the hypothesis that the CT-based fractal analysis of the trabecular bone structure may help in detecting patients with poor quality of bone before urgent spinal procedures. STUDY DESIGN: This is a retrospective analysis of prospectively collected data. METHODS: Patients in whom the dual-energy x-ray absorptiometry (DEXA) scan and lumbar spine CT were performed at an interval of no more than 3 months were randomly selected from a prospectively collected database. Diagnostic axial CT scans of L2, L3, and L4 vertebrae were processed to determine the fractal dimension (FD) of the trabecular structure of each spinal level. Box-count method and ImageJ 1.49 software were used. The FD was compared with the results of the DEXA scan: bone mineral density (BMD) and T-score by mean of correlation coefficients. Receiver operating characteristic curve analysis was later performed to determine the cutoff value of FD. RESULTS: A total of 102 vertebral levels obtained from 35 patients (mean age 60±18 years; 29 female) were analyzed. The FD was significantly higher in the group of patients with decreased bone density (DBD) (T-score<-1.0) (1.67 vs. 1.43; p<.0001) and negatively correlated with BMD (R Spearman, -0.53; p<.0001) and T-score (-0.49; p<.0001). Receiver operating characteristic curve analysis revealed that a cutoff value of FD>1.53 indicates DBD (p<.0001; area under the ROC curve [AUC], 0.84; 95% confidence interval [CI], 0.76-0.91). CONCLUSIONS: This study shows that fractal analysis of the lumbar spine CT images may be used to determine bone density before spinal instrumentation (eg, metastatic or traumatic cord compression). Further prospective studies comparing results of the fractal analysis of CT scans with quantitative CT (qCT) are warranted.