The Outcome of Molecularly Targeted Therapy after Surgical Treatment of Spinal Metastasis.

The aim of this study was to investigate outcomes of molecularly targeted therapy after surgical treatment of spinal metastasis. Participants comprised 164 patients who underwent surgical treatment of spinal metastasis, divided according to whether molecularly targeted therapy was performed. We compared survival, local recurrence of metastasis detected by imaging, the disease-free interval, relapses of neurological deterioration, and the ability to walk between groups. Molecularly targeted drugs were administered to 39 patients after surgery (TT group) and were not administered to 125 patients (non-TT group). Median survival was significantly longer in the TT group (1027 days) than in the non-TT group (439 days, p < 0.01). Local recurrence occurred in 25 patients in the non-TT group and 10 patients in the TT group. The disease-free interval did not differ between groups. Neurological deterioration was observed in three patients in the non-TT group and no patients in the TT group. The ability to walk was preserved in 97.6% of patients in the TT group and 88% of patients in the non-TT group (p = 0.12). In conclusion, molecularly targeted drugs improve survival in patients with spinal metastasis but do not alter local control of metastatic tumors.

Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial.

Importance: Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. Objective: To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. Design, Setting, and Participants: This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. Interventions: Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. Main Outcomes and Measures: The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. Results: Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. Conclusions and Relevance: This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. Trial Registration: Identifier: UMIN000030929.

Correlation Between Gait and Life Expectancy in Patients with Spinal Metastases.

BACKGROUND: Metastatic epidural spinal cord compression (MESCC) may lead to walking disability. The effect of regaining gait ability on the life expectancy of cancer patients is still unknown. To explore this issue, we evaluated the effect of gait ability recovery in nonambulatory patients after treatment for a metastatic spinal tumor. METHODS: In total, 105 patients who underwent surgery for MESCC between January 2006 and December 2016 and survived longer than 3 months were enrolled. All the patients were nonambulatory because of the MESCC and had undergone posterior decompression and fixation with intraoperative radiotherapy. At postoperative month 3, patients who had regained their gait ability were categorized as ambulatory and those who had not were categorized as nonambulatory. Age, sex, prognosis score (modified Bauer score), preoperative and postoperative Frankel grade scores, tumor origin site, Charlson comorbidity index, and survival time were compared between the groups. RESULTS: Seventy-two patients regained gait ability at postoperative month 3, and 33 patients did not. The modified Bauer score did not differ between the groups (P = 0.08); therefore, the presumptive life expectancy of the groups before treatment was not biased. The median survival time was significantly longer in the ambulatory group (610 days) than that in the nonambulatory group (181 days, P < 0.05). CONCLUSIONS: Patients who regained their gait ability after treatment for MESCC tended to live longer than those who did not, indicating that recovery of gait ability by patients with cancer is associated with improved life expectancy.

Phase 2 Clinical Trial of Separation Surgery Followed by Stereotactic Body Radiation Therapy for Metastatic Epidural Spinal Cord Compression.

PURPOSE: Stereotactic body radiation therapy (SBRT) is a postoperative treatment option for spinal metastases. Because data on surgery with SBRT are limited to retrospective studies, this single-center, single-arm, phase 2 study aimed to prospectively evaluate the outcomes of separation surgery and SBRT for metastatic epidural spinal cord compression (MESCC). METHODS AND MATERIALS: Patients with symptomatic MESCC due to a solid carcinoma were enrolled. The protocol for treatments comprised preoperative embolization, separation surgery, and spine SBRT. Surgical procedures were performed via the posterior approach, with decompression and a fixation procedure. The prescribed dose for spine SBRT was 24 Gy in 2 fractions. The primary endpoint was the 12-month local failure rate. The secondary endpoints were ambulatory functions and adverse effects. RESULTS: A total of 33 patients were registered between November 2017 and October 2019. All patients met the inclusion criteria, and all but 1 completed the protocol treatment. Of the included patients, 23 (70%) had radioresistant lesions. The Bilsky grade at registration was 1c in 3 patients, 2 in 8 patients, and 3 in 21 patients. The median follow-up duration after registration was 15 months (range, 3-35 months). Three months after the administration of treatments according to the protocol, 90% of patients (26 of 29) had disease of Bilsky grade ≤1. The 12-month local failure rate was 13%. Twenty patients could walk normally or with a cane 12 months after registration. Radiation-induced myelopathy, radiculopathy, and vertebral compression fracture were observed in 0, 1, and 6 patients, respectively. CONCLUSIONS: Separation surgery with SBRT for MESCC was effective in decompression and long-term local control. These findings suggest that larger randomized controlled trials are warranted to compare SBRT with conventional radiation therapy.

Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study.

To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC). This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions. The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively. This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.

Incidence of Unrecognized Incidental Durotomy during Surgery for Malignant Spinal Tumor.

INTRODUCTION: Cerebral spinal fluid leak from durotomy is a well-known risk with spinal surgeries. The aim of this study is to identify the incidence of unrecognized incidental durotomy during posterior surgery for spinal metastases and its risk factors. METHODS: Participants comprised 75 patients who underwent posterior spine surgery for spinal metastases between January 2012 and December 2016. Cases with apparent durotomy noticed intraoperatively were excluded. Unrecognized durotomy was diagnosed as the presence of wide subcutaneous fluid retention on magnetic resonance imaging at least 3 months postoperatively. For comparison, 50 patients who underwent cervical laminoplasty due to cervical spondylotic myelopathy were examined using the same method. We also examined correlations between occurrence of durotomy and patient characteristics such as age, type of tumor, location of tumor (ventral or dorsal), extent of tumor, and history of radiotherapy before surgery. RESULTS: Unrecognized durotomy occurred in 21 cases of spinal metastasis (26.7%) and in 1 case of cervical spondylotic myelopathy (2%), representing a significant difference between groups. Age, type of tumor, location of tumor, extent of tumor, and history of radiotherapy before surgery did not correlate significantly with occurrence of durotomy. No local trouble was observed in durotomy cases, except in one case with subcutaneous local infection. CONCLUSIONS: The incidence of unrecognized incidental durotomy is significantly higher during surgery for spinal metastases than that during surgery for degenerative disease.

Postoperative re-irradiation using stereotactic body radiotherapy for metastatic epidural spinal cord compression.

OBJECTIVE This study aimed to clarify the outcomes of postoperative re-irradiation using stereotactic body radiotherapy (SBRT) for metastatic epidural spinal cord compression (MESCC) in the authors' institution and to identify factors correlated with local control. METHODS Cases in which patients with previously irradiated MESCC underwent decompression surgery followed by spine SBRT as re-irradiation between April 2013 and May 2017 were retrospectively reviewed. The surgical procedures were mainly performed by the posterior approach and included decompression and fixation. The prescribed dose for spine SBRT was 24 Gy in 2 fractions. The primary outcome was local control, which was defined as elimination, shrinkage, or no change of the tumor on CT or MRI obtained approximately every 3 months after SBRT. In addition, various patient-, treatment-, and tumor-specific factors were evaluated to determine their predictive value for local control. RESULTS Twenty-eight cases were identified in the authors' institutional databases as meeting the inclusion criteria. The histology of the primary disease was thyroid cancer in 7 cases, lung cancer in 6, renal cancer in 3, colorectal cancer in 3, and other cancers in 9. The most common previous radiation dose was 30 Gy in 10 fractions (15 cases). The mean interval since the most recent irradiation was 16 months (range 5-132 months). The median duration of follow-up after SBRT was 13 months (range 4-38 months). The 1-year local control rate was 70%. In the analysis of factors related to local control, Bilsky grade, number of vertebral levels in the treatment target, the interval between the latest radiotherapy and SBRT, recursive partitioning analysis (RPA), the prognostic index for spinal metastases (PRISM), and the revised Tokuhashi score were not significantly correlated with local control. The favorable group classified by the Rades prognostic score achieved a significantly higher 1-year local control rate than the unfavorable group (1-year local control rate: 100% vs 33%; p < 0.01). Radiation-induced myelopathy and vertebral compression fracture were observed in 1 and 3 patients, respectively. No other grade 3 or greater toxicities were encountered. CONCLUSIONS The results indicate that spine SBRT as postoperative re-irradiation was effective, and it was especially useful for patients classified as having a good survival prognosis according to the Rades score.

Characteristics and Prognostic Factors of Bone Metastasis in Patients With Colorectal Cancer.

BACKGROUND: Because bone metastasis from colorectal cancer is rare, there are little available data regarding such cases. OBJECTIVE: The study aim was to identify the prognostic factors and characteristics associated with survival in colorectal cancer patients with bone metastasis. DESIGN: This was a retrospective study from a prospectively collected database. SETTINGS: The study took place in a multidisciplinary, high-volume tertiary cancer center in Japan. PATIENTS: Examined were records from 104 consecutive patients treated between 2004 and 2015 for bone metastasis from colorectal cancer. MAIN OUTCOME MEASURES: The primary outcome measure was overall survival. RESULTS: The spine was the most common site of bone metastasis from colorectal cancer. Right colon cancer correlated significantly with long bone metastasis (p = 0.046), whereas left colon cancer correlated significantly with spinal bone metastasis (p = 0.034). Liver metastasis was also significantly correlated with spinal bone metastasis (p = 0.036). The median interval between the primary therapy for colorectal cancer and the metachronous diagnosis of bone metastasis was 20.0 months (quartile 1 to quartile 3, 9.0-46.5 mo). The median survival time from diagnosis of bone metastasis from colorectal cancer was 5.0 months (95% CI, 4.0-9.0 mo), and the 1-year survival rate was 30.0% (95% CI, 21.1%-39.4%). Multivariate analysis revealed that ≥2 extra-bone metastatic organs, hypercalcemia, and pathologic fractures were independent poor prognostic factors (p < 0.001, 0.001, and 0.033). The number of extra-bone metastatic organs correlated with prognosis. LIMITATIONS: This study was limited by its retrospective, nonrandomized design, as well as selection bias and performance at a single institute. CONCLUSIONS: The location of colorectal cancer correlates significantly with the site of bone metastasis; the prognosis of patients with bone metastasis from colorectal cancer is very poor, and the significant prognostic factors are number of extra-bone metastatic organs, hypercalcemia, and pathologic fractures. See Video Abstract at http://links.lww.com/DCR/A589.

The significance of spinal fixation in palliative surgery for spinal metastases.

The purpose of this study is to assess appropriate fixation methods for surgical spinal stabilization for spinal metastases. 191 patients who underwent spine surgery for spinal metastases are included in this study. The surgeries included 1) posterior decompression only (29), 2) posterior decompression and fixation (153), and 3) decompression and circumferential fixation (9). We evaluated and compared all cases based upon 1) use of fixation, 2) number of levels included in the fixation, 3) type of fixation, 4) use of bone graft, 5) presence of preoperative collapse of involved vertebrae, and 6) involved area of vertebrae according to Kostuik classification. Progression of vertebral collapse on radiographs or Magnetic Resonance Imaging (MRI) or occurrence of implant failure after surgery was considered a failed case. The number of failed cases was 51 (27%). The factors that were compared between the failed and successful groups were: use of fixation (p < .01), extent of fixation (one level above and one level below affected vertebrae vs. ≧ two above and two below, p < .01), presence of preoperative collapse of affected vertebrae (p < .05), and ≧ four of six columns of vertebral involvement according to Kostuik classification (p < .01). All results were statistically significant. In conclusion, when treating metastatic spinal disease with instability, it is recommended that posterior fixation with instrumentation be used and extend at least two levels above and two below the affected vertebrae. Preoperative collapse of affected vertebrae and greater involvement of the vertebrae with metastatic disease results in greater local instability.

White Blood Cell Count and C-Reactive Protein Variations After Posterior Surgery With Intraoperative Radiotherapy for Spinal Metastasis.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To evaluate the feasibility of blood test parameters [white blood cell (WBC) count and C-reactive protein (CRP)] for predicting and diagnosing postoperative infection after posterior surgery with intraoperative radiotherapy (IORT) for spinal metastasis. SUMMARY OF BACKGROUND DATA: Posterior surgery with IORT is effective for treating spinal metastasis, as we previously reported. However, the procedure requires that the patient be transferred from the operating room to the irradiation room. In addition, the patient's general status is often poor, and the risk of postoperative infection is high. MATERIALS AND METHODS: A total of 279 patients who underwent IORT for the treatment of spinal metastasis between August 2004 and June 2013 were included in this study. The WBC count (/10 µL) and CRP level (mg/dL) were recorded in all patients preoperatively and on alternative days for up to 7 days after surgery. We assessed the development of surgical-site infection (SSI) for up to 1 month after surgery. RESULTS: SSI occurred in 41 patients (14.7%). The preoperative WBC count and CRP level did not differ between the infected and noninfected patients. The WBC counts on postoperative day (POD) 1 and POD 7 and the CRP levels on POD 7 were significantly higher in the infected patients (8.8 vs. 10.0, P=0.04; 6.1 vs. 8.8, P=0.002; 3.89 vs. 9.50, P<0.001). A receiver-operating characteristic curve analysis of the WBC count and CRP level for detecting SSI showed cutoff values of 9.6 (WBC count, POD 1), 6.5 (WBC count, POD 7), and 5.0 (CRP level, POD 7). CONCLUSIONS: A high WBC count and CRP level on POD 7 may be used to predict or detect SSI. In particular, a CRP level of 5.0 mg/dL on POD 7 strongly suggests the future development of SSI (sensitivity: 78%, specificity: 74%).

Occurrence of sudden paraplegia during follow-up period of thoracic vertebral compression fracture in a case with spinal epidural lipomatosis.

INTRODUCTION: Spinal epidural lipomatosis (SEL) involves hypertrophy of fat tissue in the extradural space, often associated with long-term corticosteroid therapy. Sometimes it causes severe spinal cord compression and the patient gradually becomes symptomatic. However, sudden onset of neurological deterioration is extremely rare. CASE PRESENTATION: We herein present a case of sudden paraplegia in a patient with thoracic SEL at 2 months after thoracic vertebral fracture, whose symptoms were consistent with a lesion at the same level as the SEL. Computed tomography scan showed no remarkable change in the degree of vertebral fracture at the time of neurological deterioration. We performed immediate decompression surgery and found hemorrhage and granulation tissue at the level of the fracture and removed it with the epidural fat tissue. The hematoma and granulation tissue were thought to be the cause of the acute deterioration. The patient recovered gradually from the paraplegia. DISCUSSION: Sudden paraplegia with SEL at the time of vertebral fracture has previously been reported, but this is the first report of SEL with delayed onset of paraplegia after an initial diagnosis of coexisting vertebral fracture.

Prognostic significance of intensive local therapy to bone lesions in renal cell carcinoma patients with bone metastasis.

We evaluated the prognostic roles of local therapy to bone metastasis (BM) in metastatic renal cell carcinoma (mRCC) patients with BM. This retrospective study included 71 mRCC patients with BM. Local therapy to BM included en bloc resection, curettage, and radiotherapy (RT). RT was classified into RT with biological effective dose (BED) ≥85 Gy and <85 Gy by its therapeutic intensity. Local therapy to BM was given for 64 patients (90 %): en bloc resection, curettage, and RT for 16, 10, and 38 patients, respectively. Fifteen patients received RT with BED ≥85 Gy. The median overall survival (OS) was 25 months (median follow-up 16 months). For 46 patients with solitary BM, patients treated with en bloc resection, curettage, and RT with BED ≥85 Gy showed significantly better OS than those treated with RT with BED <85 Gy or no local therapy (P = 0.006). Because OS was comparable among patients treated with en bloc resection, curettage, and RT with BED ≥85 Gy, these three treatment modalities were defined as "intensive local therapy". Intensive local therapy to BM was also associated with favorable OS with marginal significance (P = 0.052) in a cohort of 25 patients with multiple BM. A multivariate analysis in the whole cohort revealed that intensive local therapy to BM was independently associated with favorable OS (hazard ratio 0.23, P < 0.001) along with Memorial-Sloan Kettering Cancer Center risk category (P < 0.001). Thus, intensive local therapy to BM might improve OS in mRCC patients with BM including multiple BM.

Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases.

PURPOSE: Posterior surgery with intraoperative radiotherapy for spinal metastases offers effective therapy, as we have reported previously. However, the procedure involves transfer from the operating room to the radiotherapy room, and as these patients are somewhat immunocompromised, the risk of postoperative surgical site infection (SSI) may be increased. The aim of our study was to identify risk factors and patient characteristics associated with postoperative SSI following posterior fixation surgery and intraoperative radiotherapy for spinal metastases. METHODS: Participants comprised 279 patients who underwent IORT for the treatment of spinal metastases between August 2004 and June 2013. Patients who suffered SSI within 1 month after surgery were categorized as infected, and all others were categorized as non-infected. We compared factors of age, sex, use of pre-operative corticosteroid, medical history of diabetes, prognosis scores (Tomita, Tokuhashi, and Katagiri), pre- and postoperative Frankel scale scores, site of tumor origin, administration of pre-operative radiotherapy, operation time, intraoperative blood loss, intraoperative irradiation dose, and pre- and postoperative performance status between groups. RESULTS: SSI occurred in 41 patients (14.7%). Katagiri's and Tokuhashi's prognostic scores (P < 0.05 each), postoperative Frankel scale score (P < 0.01), administration of pre-operative radiotherapy (P < 0.05), and postoperative performance status (P < 0.05) all correlated significantly with occurrence of SSI. Multivariate analysis using those factors revealed administration of pre-operative radiotherapy as a factor independently associated with SSI (P < 0.05). CONCLUSIONS: Patient prognosis, postoperative ambulatory function, and pre-operative radiotherapy were risk factors for SSI in patients with spinal metastases. Duration of surgery and intraoperative blood loss were not associated with occurrence of SSI.

META: an MRI-based scoring system differentiating metastatic from osteoporotic vertebral fractures.

BACKGROUND CONTEXT: Magnetic resonance imaging (MRI) is useful for the differential diagnosis of osteoporotic vertebral fractures (OVFs) and metastatic vertebral fractures (MVFs), but no single finding is absolutely conclusive. PURPOSE: The purpose of the present study was to create a scoring system to facilitate the correct diagnosis of MVFs by integrating several MRI findings. STUDY DESIGN: This is a retrospective and single-center observational study that attempts to create a diagnostic scoring system by discriminant analysis. PATIENTS SAMPLE: We included 100 OVFs and 100 MVFs in thoracolumbar vertebrae of which MR images were obtained within 60 days from the suspected time of fractures. OUTCOME MEASURES: The sensitivity and specificity of known important MRI findings were assessed, and the classification accuracy of the scoring system was investigated. METHODS: Seven MRI findings of these fractures were analyzed to evaluate their sensitivity and specificity. Using these findings as variables, discriminant analysis was performed in 140 fractures as a training set, and the classification accuracy was calculated in the remaining 60 fractures as a test set. Additionally, the images of these 60 fractures were reviewed by another blinded reviewer to investigate the interobserver reliability of each finding. RESULTS: All findings had high specificity with low-to-moderate sensitivity. Eight variables were selected in the final discriminant function. A simpler scoring system (MRI Evaluation Totalizing Assessment [META]) was created by approximating the coefficients and the constant term by integral numbers. The classification accuracy was calculated to be 96.6% in the test set. The interobserver reliability of the key findings varied, but the final discrimination conducted by META had the high agreement between the two reviewers (κ=0.93). CONCLUSIONS: This novel scoring system, META, could prove to be a useful tool for the differential diagnosis of OVFs and MVFs. It is simple and physician friendly, yet highly accurate.

Antibiotic-impregnated cement embedding technique for spinal instrumentation infections.

BACKGROUND AND STUDY AIMS: When surgical site infection occurs in patients with an instrumented spine, the management of infection is challenging because a biofilm is formed around the metallic surface of the implant. Although a wide variety of methods to salvage implants has been developed, previously reported methods reduce the patients' quality of life and are frequently time consuming and costly. PATIENTS AND METHODS: We performed a cement embedding technique in 13 consecutive patients with infection after spinal instrumentation. After meticulous open débridement, the metallic implants were embedded using polymethylmethacrylate (PMMA) mixed with antibiotics. Antibiotics were selected in each case according to the pathogens and their sensitivity. The wound was primarily closed. We did not restrict the patients' activity postoperatively. The implants were not removed unless it was necessary for further procedures. RESULTS: Nine patients, including those infected by methicillin-resistant Staphylococcus aureus (MRSA), were cured by débridement and PMMA embedding followed by systemic antibiotic treatment. No complications were reported. CONCLUSIONS: The antibiotic-impregnated PMMA embedding technique is an effective method for the treatment of spinal instrumentation infections. It is easy to perform and is also effective for MRSA infection.

Optimal schedule of preoperative embolization for spinal metastasis surgery.

STUDY DESIGN: A retrospective study. OBJECTIVE: To investigate the relationship between intraoperative blood loss during spinal metastasis surgery and the surgical delay after preoperative embolization. SUMMARY OF BACKGROUND DATA: Delaying surgery after embolization is thought to diminish its effectiveness because of revascularization, but there has been no scientific study that supports this hypothesis. METHODS: We reviewed data from 66 consecutive posterior palliative decompression surgical procedures for spinal metastasis from thyroid and renal cell carcinoma (39 thyroid and 27 renal) in 58 patients between 2004 and 2012. All patients underwent preoperative angiography. The timing of preoperative embolization was determined on the basis of the operating room and interventional radiologist schedules. Excluding one case who did not receive embolization due to lack of hypervascularity, we analyzed 65 cases to compare intraoperative blood loss according to the completeness of embolization and the time lapse between embolization and surgery. RESULTS: Surgical procedures were performed on the same day of embolization in 21 cases (same day-group), and on the next day after embolization in 39 cases (next-day group). Five surgical procedures were performed 2 days later. The intraoperative blood loss was significantly lesser with complete embolization than with partial embolization (mean ± standard deviation: 809 ± 835 vs. 1210 ± 904 mL, P = 0.03). Among those with complete embolization, the intraoperative blood loss as well as the perioperative transfusion requirement was significantly lesser in the same-day group than in the next-day group (mean ± standard deviation: blood loss: 433 ± 376 vs. 1012 ± 974 mL, P = 0.01; transfusion requirement: 1.5 ± 1.7 vs. 4.2 ± 4.1 units, P = 0.04). CONCLUSION: Preoperative embolization showed greater effectiveness in reducing intraoperative blood loss when surgery for spinal metastasis was performed on the same day than when surgery was delayed. Surgery should be performed on the same day of embolization if possible. LEVEL OF EVIDENCE: 4.

Incidence of, and risk factors for, postoperative venous thromboembolism in patients with benign or malignant musculoskeletal tumors.

BACKGROUND: Venous thromboembolism is a serious complication after surgery for malignant musculoskeletal tumors in the lower extremity. However, the incidence of postoperative venous thromboembolism in patients with benign musculoskeletal tumors and musculoskeletal tumors in the upper extremity or trunk remains unclear. Identifying risk factors may provide useful information for selecting patients who should receive chemoprophylaxis. METHODS: A retrospective study of 833 patients with musculoskeletal tumors who underwent surgery was conducted. Patients were divided into four groups: 364 patients with benign tumors in the upper extremity or trunk (group 1); 315 patients with benign tumors in the lower extremity or pelvis (group 2); 50 patients with malignant tumors in the upper extremity or trunk (group 3); and 104 patients with malignant tumors in the lower extremity or pelvis (group 4). The incidence of venous thromboembolism was investigated, and risk factors were examined for group 4. RESULTS: The incidence of postoperative venous thromboembolism was 0, 0.95, 0, and 4.8 % in groups 1, 2, 3, and 4, respectively. The incidence of venous thromboembolism in the malignant tumor group (groups 3 + group 4) was significantly higher than that in the benign tumor group (group 1 + group 2). The incidence of postoperative venous thromboembolism in the upper extremity or trunk group (group 1 + group 3) was significantly lower than that in the lower extremity or pelvis group (group 2 + group 4). In group 4, a higher incidence of postoperative venous thromboembolism was significantly correlated with a history of cerebrovascular disease and surgery in the prone position. CONCLUSIONS: Patients with malignant tumors in the lower extremity or pelvis, particularly those with a history of cerebrovascular disease and surgery in a prone position, were at high risk of venous thromboembolism. Patients with benign tumors in the lower extremity or pelvis were at intermediate risk. This is important information for predicting the incidence of postoperative venous thromboembolism and determining who should receive chemoprophylaxis after surgery for musculoskeletal tumors.