The role of minimally invasive surgery within a multidisciplinary approach for patients with metastatic spine disease over a decade: A systematic review.

BACKGROUND: Metastatic spine disease (MSD) occurs commonly in cancer patients causing pain, spinal instability, devastating neurological compromise, and decreased quality of life. Oncological patients are often medically complex and frail, precluding them form invasive procedures. To address this issue, minimally invasive spinal surgery (MISS) techniques are desirable. The aim of this study is to review published peer-reviewed literature and ongoing clinical trials to provide current state of the art. METHODS: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, assessing MISS in MSD patients for the period 2013-2023. Innovations under development were assessed by querying and reviewing data from currently enrolling U.S. registered clinical trials. RESULTS: From 3,696 articles, 50 studies on 3,196 patients focused on spinal oncology MISS. The most commonly reported techniques were vertebral augmentation (VA), percutaneous spinal instrumentation, and radiofrequency ablation (RFA). Surgical instrumentation/stabilization techniques were reported in 10/50 articles for a total of 410 patients. The majority of studies focused on pain as a primary outcome measure, with 28/50 studies reporting a significant improvement in pain following intervention. In the United States, 13 therapeutic trials are currently recruiting MSD patients. Their main focus includes radiosurgery, VA and/or RFA, and laser interstitial thermal therapy. CONCLUSIONS: Due to their medical complexity and increased fragility, MSD patients may benefit from minimally invasive approaches. These strategies are effective at mitigating pain and preventing neurological deterioration, while providing other advantages including ease to start/resume systemic/radiotherapy treatment(s).

The iliac kickstand screw: anatomic CT analysis of screw trajectory and osseous corridor for screw placement.

INTRODUCTION: The 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium. OBJECTIVE: Using a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw. METHODS: 50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured. RESULTS: 50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes. CONCLUSIONS: The novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.

Seasonal Effects on Surgical Site Infections Following Spine Surgery.

BACKGROUND: Studies investigating seasonality as a risk factor for surgical site infections (SSIs) after spine surgery show mixed results. This study used national data to analyze seasonal effects on spine surgery SSIs. METHODS: National Surgical Quality Improvement Program data (2011-2018) were queried for posterior cervical fusions (PCFs), cervical laminoplasties, posterior lumbar fusions (PLFs), lumbar laminectomies, and deformity surgeries. Patients aged >89 and procedures for tumors, fractures, infections, and nonelective indications were excluded. Patients were divided into warm (admitted April-September) and cold (admitted October-March) seasonal groups. End points were SSIs and reoperations for wound débridement/drainage. Stratified analyses were performed by surgery type and pre-versus postdischarge infections. RESULTS: Overall (N = 208,291), SSIs were more likely in the warm season (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.08-1.23, P < 0.0001) and for PCFs (OR 1.40, 95% CI 1.08-1.80, P = 0.011), PLFs (OR 1.15, 95% CI 1.04-1.28, P = 0.006), and lumbar laminectomies (OR 1.13, 95% CI 1.03-1.25, P = 0.014). Postdischarge infections were also more likely in the warm season overall (OR 1.15, 95% CI 1.07-1.23, P < 0.0001) and for PCFs (OR 1.32, 95% CI 1.01-1.73, P = 0.041), PLFs (OR 1.14, 95% CI 1.03-1.27, P = 0.014), and lumbar laminectomies (OR 1.15, CI 1.04-1.27, P = 0.007). In-hospital infections were more likely during the warm season only for PCFs (OR 2.54, 95% CI 1.06-6.10, P = 0.037). Reoperations for infection were more likely during the warm season for PLFs (OR 1.29, 95% CI 1.08-1.54, P = 0.005). CONCLUSIONS: PCF, PLF, and lumbar laminectomy performed during the warm season had significantly higher odds of SSI, especially postdischarge SSIs. Reoperation rates for wound management were significantly increased during the warm season for PLFs. Identifying seasonal causes merits further investigation and may influence surgeon scheduling and expectations.

Intraoperative Navigation in Spine Surgery: Effects on Complications and Reoperations.

INTRODUCTION: Intraoperative navigation during spine surgery improves pedicle screw placement accuracy. However, limited studies have correlated the use of navigation with clinical factors, including operative time and safety. In the present study, we compared the complications and reoperations between surgeries with and without navigation. METHODS: The National Surgical Quality Improvement Project database was queried for posterior cervical and lumbar fusions and deformity surgeries from 2011 to 2018 and divided by navigation use. Patients aged >89 years, patients with deformity aged <25 years, and patients undergoing surgery for tumors, fractures, infections, or nonelective indications were excluded. The demographics and perioperative factors were compared via univariate analysis. The outcomes were compared using multivariable logistic regression adjusting for age, sex, body mass index, American Society of Anesthesiologists class, surgical region, and multiple treatment levels. The outcomes were also compared stratifying by revision status. RESULTS: Navigation surgery patients had had higher American Society of Anesthesiologists class (P < 0.0001), more multiple level surgeries (P < 0.0001), and longer operative times (P < 0.0001). The adjusted analysis revealed that navigated lumbar surgery had lower odds of complications (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.77-0.90; P < 0.0001), blood transfusion (OR, 0.79; 95% CI, 0.72-0.87; P < 0.0001), and wound debridement and/or drainage (OR, 0.66; 95% CI, 0.44-0.97; P = 0.04) compared with non-navigated lumbar surgery. Navigated cervical fusions had increased odds of transfusions (OR, 1.53; 95% CI, 1.06-2.23; P = 0.02). Navigated primary fusion had decreased odds of complications (OR, 0.91; 95% CI, 0.85-0.98; P = 0.01). However, no differences were found in revisions (OR, 0.89; 95% CI, 0.69-1.14; P = 0.34). CONCLUSIONS: Navigated surgery patients experienced longer operations owing to a combination of the time required for navigation, more multilevel procedures, and a larger comorbidity burden, without differences in the incidence of infection. Fewer complications and wound washouts were required for navigated lumbar surgery owing to a greater proportion percentage of minimally invasive cases. The combined use of navigation and minimally invasive surgery might benefit patients with the proper indications.

Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results.

OBJECTIVE: The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. METHODS: Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance. RESULTS: Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°-36.3°), lateral vertebral body purchase was 13.4 mm (range, 0-28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9-31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative. CONCLUSION: Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.

Comparison of Patient Preference, Understanding, and Sentiment for Minimally Invasive Versus Open Spine Surgery.

STUDY DESIGN: Retrospective questionnaire analysis. OBJECTIVE: The goal of this study was to analyze patients' understanding and preferences for minimally invasive spine (MIS) versus open spine surgery. SUMMARY OF BACKGROUND DATA: MIS surgery is increasing in prevalence. However, there is insufficient literature to evaluate how the availability of MIS surgery influences the patients' decision-making process and perceptions of spine procedures. METHODS: A survey was administered to patients who received a microdiscectomy or transforaminal lumbar interbody fusion between 2016 and 2020. All eligible patients were stratified into two cohorts based on the use of minimally invasive techniques. Each cohort was administered a survey that evaluated patient preferences, perceptions, and understanding of their surgery. RESULTS: One hundred fifty two patients completed surveys (MIS: 88, Open: 64). There was no difference in time from surgery to survey (MIS: 2.1 ±â€Š1.4 yrs, Open: 1.9 ±â€Š1.4 yrs; P = 0.36) or sex (MIS: 56.8% male, Open: 53.1% male; P = 0.65). The MIS group was younger (MIS: 53.0 ±â€Š16.9 yrs, Open: 58.2 ±â€Š14.6 yrs; P = 0.05). More MIS patients reported that their technique influenced their surgeon choice (MIS: 64.0%, Open: 37.5%; P  < 0.00001) and increased their preoperative confidence (MIS: 77.9%, Open: 38.1%; P  < 0.00001). There was a trend towards the MIS group being less informed about the intraoperative specifics of their technique (MIS: 35.2%, Open: 23.4%; P = 0.12). More of the MIS cohort reported perceived advantages to their surgical technique (MIS: 98.8%, Open: 69.4%; P < 0.00001) and less reported disadvantages (MIS: 12.9%, Open: 68.8%; P < 0.00001). 98.9% and 87.1% of the MIS and open surgery cohorts reported a preference for MIS surgery in the future. CONCLUSION: Patients who received a MIS approach more frequently sought out their surgeons, were more confident in their procedure, and reported less perceived disadvantages following their surgery compared with the open surgery cohort. Both cohorts would prefer MIS surgery in the future. Overall, patients have positive perceptions of MIS surgery.Level of Evidence: 3.

Multidisciplinary management of metastatic spine disease: initial symptom-directed management.

In the past 2 decades, a deeper understanding of the cancer molecular signature has resulted in longer longevity of cancer patients, hence a greater population, who potentially can develop metastatic disease. Spine metastases (SM) occur in up to 70% of cancer patients. Familiarizing ourselves with the key aspects of initial symptom-directed management is important to provide SM patients with the best patient-specific options. We will review key components of initial symptoms assessment such as pain, neurological symptoms, and spine stability. Radiographic evaluation of SM and its role in management will be reviewed. Nonsurgical treatment options are also presented and discussed, including percutaneous procedures, radiation, radiosurgery, and spine stereotactic body radiotherapy. The efforts of a multidisciplinary team will continue to ensure the best patient care as the landscape of cancer is constantly changing.

Correction to: Adult spinal deformity surgery: the effect of surgical start time on patient outcomes and cost of care.

The original version of this article unfortunately contained a mistake. The first name of the author "Samuel Z. Maron" was incorrectly provided as "Sam" instead of "Samuel".

Adult spinal deformity surgery: the effect of surgical start time on patient outcomes and cost of care.

PURPOSE: There are reports investigating the effect of surgical start time (SST) on outcomes, length of stay (LOS) and cost in various surgical disciplines. However, this has not been studied in spine deformity surgery to date. This study compares outcomes for patients undergoing spinal deformity surgery based on SST. METHODS: Patients at a single academic institution from 2008 to 2016 undergoing elective spinal deformity surgery (defined as fusing ≥ 7 segments) were divided by SST before or after 2 PM. Co-primary outcomes were LOS and direct costs. Secondary outcomes included delayed extubation, ICU stay, complications, reoperation, non-home discharge, and readmission rates. RESULTS: There were 373 surgeries starting before 2 PM and 79 after 2 PM. The cohorts had similar demographics including age, sex, comorbidity burden, and levels fused. The late SST cohort had shorter operation durations (p = 0.0007). Multivariable linear regression showed no differences in LOS (estimate 0.4 days, CI - 1.2 to 2.0, p = 0.64) or direct cost (estimate $3652, 95% CI - $1449 to $8755, p = 0.16). Multivariable logistic regression revealed the late SST cohort was more likely to have delayed extubation (OR 2.6, 95% CI 1.4-4.9, p = 0.004) and non-home discharge (OR 2.2, 95% CI 1.1-4.2, p = 0.03). All other secondary outcomes were non-significant. CONCLUSION: Patients undergoing spinal deformity surgery before and after 2 PM have similar LOS and cost of care. However, the late SST cohort had increased likelihood of delayed extubation and non-home discharges, which increase cost in bundled payment models. These findings can be utilized in OR scheduling to optimize outcomes and minimize cost.

Frailty status as a predictor of 3-month cognitive and functional recovery following spinal surgery: a prospective pilot study.

BACKGROUND CONTEXT: As increasing numbers of elderly Americans undergo spinal surgery, it is important to identify which patients are at highest risk for poor cognitive and functional recovery. Frailty is a geriatric syndrome that has been closely linked to poor outcomes, and short-form screening may be a helpful tool for preoperative identification of at-risk patients. PURPOSE: This study aimed to conduct a pilot study on the usefulness of a short-form screening tool to identify elderly patients at increased risk for prolonged cognitive and functional recovery following elective spine surgery. STUDY DESIGN/SETTING: This is a prospective, comparative cohort study. PATIENT SAMPLE: The sample comprised 100 patients over age 65 who underwent elective spinal surgery (cervical or lumbar) at a single, large academic medical center from 2013 to 2014. OUTCOME MEASURES: Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, Postoperative Quality of Recovery Scale (PQRS), and instrumental activities of daily living (IADL) scores were the outcome measures. METHODS: Included patients were assessed with the FRAIL scale and stratified as robust, pre-frail, or frail. The PQRS and IADL scores were also obtained. Patients were re-examined at 1 day, 3 days, 1 month, and 3 months after surgery for cognitive recovery at 3 months, and secondarily, functional recovery at 3 months. RESULTS: At 3 months, only 50% of frail patients had recovered to their cognitive baseline compared with 60.7% of pre-frail and 69.2% of robust patients (trend). At 3 months, 66.7% of frail patients had recovered to their functional baseline compared with 57% of pre-frail and 76.9% of robust patients (trend). Using multivariate regression modeling, at 3 months, frail patients were less likely to have recovered to their cognitive baseline compared with pre-frail and robust patients (odds ratio 0.39, confidence interval 0.131-1.161). CONCLUSIONS: This pilot study demonstrates a trend toward poorer cognitive recovery 3 months following elective spinal surgery for frail patients. Frailty screening can help preoperatively identify patients who may experience protracted cognitive and functional recovery.

Progressive visual loss following rupture of an intracranial dermoid cyst.

A 51-year-old man with several months of headache and progressive visual decline was found to have bilateral optic disc pallor with significant impairment of visual acuity. Despite a thorough ophthalmologic evaluation, the cause of visual loss could not be elucidated. MRI of the brain revealed a lesion in the left anterior Sylvian fissure as well as disseminated foci of subarachnoid fat consistent with a diagnosis of a ruptured dermoid cyst. The decision for open surgical resection was chosen to minimize the risk of cyst re-rupture and further visual or neurologic decline. The diagnosis of dermoid cyst was confirmed at the time of surgery. Vasospasm-induced ischemia of the optic nerves, optic chiasm or bilateral optic tracts secondary to the inflammatory reaction following cyst rupture is the most likely mechanism of visual loss in this patient. To the authors' knowledge, this report represents the first reported case of visual loss secondary to rupture of an intracranial dermoid cyst not related to mass effect of the tumor on the optic apparatus, visual pathways or visual cortex.