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1.
J Neurosurg Spine ; : 1-8, 2020 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-32244218

RESUMO

OBJECTIVE: Metastatic spinal cord compression (MSCC) imposes significant impairment on patient quality of life and often requires immediate surgical intervention. In this study the authors sought to estimate the impact of surgical intervention on patient quality of life in the form of mean quality-adjusted life years (QALY) gained and identify factors associated with positive outcomes. METHODS: The authors performed a retrospective chart review and collected data for patients who had neurological symptoms resulting from radiologically and histologically confirmed MSCC and were treated with surgical decompression during the last 12 years. RESULTS: A total of 151 patients were included in this study (mean age 60.4 years, 57.6% males). The 5 most common metastatic tumor types were lung, multiple myeloma, renal, breast, and prostate cancer. The majority of patients had radioresistant tumors (82.7%) and had an active primary site at presentation (67.5%). The median time from tumor diagnosis to cord compression was 12 months and the median time from identification of cord compression to death was 4 months. Preoperative presenting symptoms included motor weakness (70.8%), pain (70.1%), sensory disturbances (47.6%), and bowel or bladder disturbance (31.1%). The median estimated blood loss was 500 mL and the average length of hospital stay was 10.3 days. About 18% of patients had postoperative complications and the mean follow-up was 7 months. The mean pre- and postoperative ECOG (Eastern Cooperative Oncology Group) performance status grades were 3.2 and 2.4, respectively. At follow-up, 58.3% of patients had improved status, 31.5% had no improvement, and 10.0% had worsening of functional status. The mean QALY gained per year in the entire cohort was 0.55. The mean QALY gained in the first 6 months was 0.1 and in the first year was 0.4. For patients who lived 1-2, 2-3, 3-4, or 4-5 years, the mean QALY gained were 0.8, 1.4, 1.7, and 2.3, respectively. Preoperative motor weakness, bowel dysfunction, bladder dysfunction, and ASA (American Society of Anesthesiologists) class were identified as independent predictors inversely associated with good outcome. CONCLUSIONS: The mean QALY gained from surgical decompression in the first 6 months and first year equals 1.2 months and 5 months of life in perfect health, respectively. These findings suggest that surgery might also be beneficial to patients with life expectancy < 6 months.

2.
Spine J ; 2020 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-32087387

RESUMO

BACKGROUND CONTEXT: The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS. PURPOSE: To prospectively validate the NESMS. STUDY DESIGN: Prospective longitudinal observational cohort study. PATIENT SAMPLE: Patients, aged 18 and older, presenting for treatment with spinal metastatic disease. OUTCOME MEASURES: One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary). METHODS: The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI). RESULTS: This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall. CONCLUSIONS: This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy.

3.
J Neurosurg Spine ; : 1-6, 2020 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-31952035

RESUMO

OBJECTIVE: Minimal access ablative techniques have emerged as a less invasive option for spinal metastatic disease reduction and separation from neural tissue. Compared with heat-based ablation modalities, percutaneous image-guided cryoablation allows for more distinct visualization of treatment margins. The authors report on a series of patients undergoing MRI-guided cryoablation as a feasible method for treating spinal metastatic disease. METHODS: A total of 14 patients with metastatic spine disease undergoing MR-monitored cryoablation were prospectively enrolled. Procedures were performed in an advanced imaging operating suite with the use of both CT and MRI to gain access to the spinal canal and monitor real-time cryoablation. RESULTS: The average age was 54.5 years (range 35-81 years). The mean preoperative Karnofsky Performance Status score was 79.3 (range 35-90). The average radiographic follow-up was 7.1 months (range 25-772 days), and the average clinical follow-up was 9.8 months (range 7-943 days). In 10 patients with epidural disease, 7 patients underwent postprocedural imaging, and of these 71% (5/7) had stable or reduced radiographic disease burden. Bone regrowth was observed in 63% (5/8) of patients with bone ablation during the treatment who had postoperative imaging. Pre- and postoperative visual analog scale scores were obtained, and a significant reduction in these scores was found following ablation. There were no complications. CONCLUSIONS: MR-guided cryoablation is a minimally invasive treatment option for metastatic spine disease. In patients with epidural disease, the majority experienced tumor reduction or arrest at follow-up. In addition, pain was significantly improved following ablation. The average hospital stay was short, and the procedure was safe in a range of patients who are otherwise not ideal candidates for standard treatment.

4.
Clin Neurol Neurosurg ; 188: 105574, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31707291

RESUMO

OBJECTIVES: To describe patient-specific characteristics associated with non-operative failure leading to surgery. PATIENTS AND METHODS: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. RESULTS: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). CONCLUSION: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.

6.
J Neurosurg Spine ; : 1-7, 2019 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-31881536

RESUMO

OBJECTIVE: Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries. METHODS: The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014. RESULTS: Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital. CONCLUSIONS: Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.

7.
Spine J ; 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31712164

RESUMO

BACKGROUND CONTEXT: There are several prognostic scores available that intend to inform decision-making for patients with spinal metastases. Many of these have not been found to reliably predict survival across the continuum of care. Recently, our group developed the New England Spinal Metastasis Score (NESMS). While the NESMS demonstrated many of the necessary attributes of a useful prediction tool, it has yet to be validated prospectively. PURPOSE: To describe the prospective observational study of spinal metastasis treatment (POST). This investigation examined the performance of the NESMS, compared its predictive capacity with other scoring systems and determined its ability to identify patients who benefit the most from surgery. STUDY DESIGN: Prospective observational study at two medical centers. PATIENT SAMPLE: Patients age 18 and older with spinal metastases involving the spine. OUTCOME MEASURES: Survival, post-treatment morbidity and health-related quality of life outcomes. METHODS: The POST study assessed patients at baseline and at 1-month, 3-month, 6-month, and 12-month time-points. During the baseline assessment patient demographics, past medical history and assessment of co-morbidities, surgical history, primary tumor histology, and ambulatory status were recorded along with the designated treatment strategy (eg, operative or nonoperative). The NESMS and other predictive scores for each patient were calculated based on baseline data. Study-specific surveys administered at all time-points consisted of the EuroQuol 5-Dimension and Short-Form (SF)-12, Visual Analog Scale (VAS) for pain, and PROMIS assessment of global health. RESULTS: Two hundred patients were enrolled in POST from 2017 to 2019. Patients were followed to one of the two predetermined study end-points (ie, mortality, or completion of the 12-month follow-up). Survival was considered the principle dependent variable. Post-treatment morbidity and health-related quality of life outcomes were considered secondarily. Analyses, by aim, relied on Cox proportional hazards regression, repeated measures logistic regression, propensity score matching and multivariable logistic regression. CONCLUSION: The POST's findings are anticipated to provide evidence regarding the prognostic capabilities of the NESMS as well as that of other popular grading schemes for survival, post-treatment complications and physical as well as mental function.

8.
J Neurosurg Spine ; : 1-7, 2019 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-31491759

RESUMO

OBJECTIVE: Recent advances in computer vision have revolutionized many aspects of society but have yet to find significant penetrance in neurosurgery. One proposed use for this technology is to aid in the identification of implanted spinal hardware. In revision operations, knowing the manufacturer and model of previously implanted fusion systems upfront can facilitate a faster and safer procedure, but this information is frequently unavailable or incomplete. The authors present one approach for the automated, high-accuracy classification of anterior cervical hardware fusion systems using computer vision. METHODS: Patient records were searched for those who underwent anterior-posterior (AP) cervical radiography following anterior cervical discectomy and fusion (ACDF) at the authors' institution over a 10-year period (2008-2018). These images were then cropped and windowed to include just the cervical plating system. Images were then labeled with the appropriate manufacturer and system according to the operative record. A computer vision classifier was then constructed using the bag-of-visual-words technique and KAZE feature detection. Accuracy and validity were tested using an 80%/20% training/testing pseudorandom split over 100 iterations. RESULTS: A total of 321 total images were isolated containing 9 different ACDF systems from 5 different companies. The correct system was identified as the top choice in 91.5% ± 3.8% of the cases and one of the top 2 or 3 choices in 97.1% ± 2.0% and 98.4 ± 13% of the cases, respectively. Performance persisted despite the inclusion of variable sizes of hardware (i.e., 1-level, 2-level, and 3-level plates). Stratification by the size of hardware did not improve performance. CONCLUSIONS: A computer vision algorithm was trained to classify at least 9 different types of anterior cervical fusion systems using relatively sparse data sets and was demonstrated to perform with high accuracy. This represents one of many potential clinical applications of machine learning and computer vision in neurosurgical practice.

9.
World Neurosurg ; 131: e514-e520, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31394365

RESUMO

BACKGROUND: The cervicothoracic junction (CTJ) has often been identified as an area of biomechanical vulnerability; however, few studies have examined the relative merits of extending fusions across this area. In this study, we sought to investigate the tradeoffs involved in fusing across the CTJ in cases of elective posterior cervical laminectomy and fusion. METHODS: We conducted a single-institution retrospective cohort study of patients undergoing elective, multilevel, posterior cervical decompression and fusion for degenerative cervical stenosis. Data were collected on baseline clinical and radiographic variables as well any subsequent complications or reoperations. Outcomes measures were compared between those who received fusion stopping at C7 with those who received fusion crossing the CTJ, with multivariate logistic regression used to adjust for any known confounders. RESULTS: Patients whose fusion crossed the CTJ were found to have more levels fused (mean: 5.8 vs. 3.5 levels, P < 0.0001), longer surgical times (mean: 216 vs. 149 minutes, P < 0.0001), and higher estimated blood losses (mean: 475 vs. 116 mL, P < 0.0001) despite no significant differences in number of levels decompressed (mean: 4.2 vs. 4.3 levels, P = 0.63). The groups did not differ in overall reoperation rate (10.8% vs. 9.4%, P = 1.00), but crossing the CTJ was associated with a higher rate of wound dehiscence (7.8% vs. 0%, P = 0.03). This difference persisted in multivariate analysis (P < 0.001). CONCLUSIONS: Crossing the CTJ was associated with increased surgical time, estimated blood loss, and the rates of wound dehiscence. These tradeoffs should be considered in planning posterior cervical decompression and fusion procedures.


Assuntos
Vértebras Cervicais/cirurgia , Laminectomia/métodos , Compressão da Medula Espinal/cirurgia , Fusão Vertebral/métodos , Estenose Espinal/cirurgia , Espondilose/cirurgia , Vértebras Torácicas/cirurgia , Idoso , Perda Sanguínea Cirúrgica , Estudos de Coortes , Descompressão Cirúrgica , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Compressão da Medula Espinal/etiologia , Estenose Espinal/complicações , Espondilose/complicações
10.
Artigo em Inglês | MEDLINE | ID: mdl-31313813

RESUMO

BACKGROUND: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, with symptoms ranging from headaches to coma. Operative evacuation is the treatment of choice. Subdural reaccumulation leading to reoperation is a vexing postoperative complication. OBJECTIVE: To present a novel technique for intraoperative aspiration of pneumocephalus via a subdural drain following SDH evacuation as a method of reducing potential subdural space and promoting cerebral expansion, thereby decreasing SDH recurrence. METHODS: In this retrospective study, 15 patients who underwent operative evacuation of cSDH between 2008 and 2015 were assessed. Six patients underwent a small craniotomy with intraoperative pneumocephalus aspiration. These patients were matched by age, gender, and anticoagulation status to 9 patients who underwent evacuation of SDH without pneumocephalus aspiration. Quantitative volumetric analysis was performed on the preoperative, postoperative, and 1-mo follow-up computed tomography scan to assess the subdural volume. RESULTS: In the immediate postoperative period, there was no difference in the percentage of residual subdural fluid between the aspiration and control groups (0.291 vs 0.251; P = 1.00). There was a decrease in amount of pneumocephalus present when the aspiration technique was applied (0.182 vs 0.386; P = .041). At 1-mo follow-up, there was a decrease in the residual cSDH volume between the aspiration and the control groups (28.7 mL vs 60.8 mL; P = .011). The long-term evacuation rate was greater in the aspiration group (75.4% vs 51.6%; P = .015). CONCLUSION: Intraoperative aspiration of cSDH cavity is a safe technique that may enhance cerebral expansion and reduce likelihood of cSDH recurrence.

12.
Cancer ; 125(15): 2631-2637, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30985913

RESUMO

BACKGROUND: Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. This study evaluated the effects of operative and nonoperative management on maintenance of ambulatory function and survival for patients treated for spinal metastases. METHODS: Propensity matching was used to yield an analytic sample in which operatively and nonoperatively treated patients were similar with respect to key baseline covariates. The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. It evaluated the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes. RESULTS: Nine hundred twenty-nine individuals eligible for inclusion were identified, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation (3% vs 16%; relative risk [RR], 0.16; 95% confidence interval [CI], 0.06-0.46) as well as a reduced risk of 6-month mortality (20% vs 29%; RR, 0.69; 95% CI, 0.49-0.98). CONCLUSIONS: These results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients' preferences regarding surgical risk, mortality, and ambulatory status.

13.
Neurosurgery ; 84(1): E53-E55, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202868

RESUMO

QUESTION: Does early surgical intervention improve outcomes for patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient and conflicting evidence regarding the effect of timing of surgical intervention on neurological outcomes in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient It is suggested that "early" surgery be considered as an option in patients with thoracic and lumbar fractures to reduce length of stay and complications. The available literature has defined "early" surgery inconsistently, ranging from <8 h to <72 h after injury. Strength of Recommendation: Grade B The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_10.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Planejamento de Assistência ao Paciente , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/cirurgia
14.
Neurosurgery ; 84(1): E24-E27, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202904

RESUMO

QUESTION 1: Are there classification systems for fractures of the thoracolumbar spine that have been shown to be internally valid and reliable (ie, do these instruments provide consistent information between different care providers)? RECOMMENDATION 1: A classification scheme that uses readily available clinical data (eg, computed tomography scans with or without magnetic resonance imaging) to convey injury morphology, such as Thoracolumbar Injury Classification and Severity Scale or the AO Spine Thoracolumbar Spine Injury Classification System, should be used to improve characterization of traumatic thoracolumbar injuries and communication among treating physicians. Strength of Recommendation: Grade B. QUESTION 2: In treating patients with thoracolumbar fractures, does employing a formally tested classification system for treatment decision-making affect clinical outcomes? RECOMMENDATION 2: There is insufficient evidence to recommend a universal classification system or severity score that will readily guide treatment of all injury types and thereby affect outcomes. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_2.


Assuntos
Vértebras Lombares/cirurgia , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/classificação , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Neurocirurgiões , Fraturas da Coluna Vertebral/cirurgia , Resultado do Tratamento
15.
Neurosurgery ; 84(1): E43-E45, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202931

RESUMO

QUESTION: Does the active maintenance of arterial blood pressure after injury affect clinical outcomes in patients with thoracic and lumbar fractures? RECOMMENDATIONS: There is insufficient evidence to recommend for or against the use of active maintenance of arterial blood pressure after thoracolumbar spinal cord injury. Grade of Recommendation: Grade Insufficient However, in light of published data from pooled (cervical and thoracolumbar) spinal cord injury patient populations, clinicians may choose to maintain mean arterial blood pressures >85 mm Hg in an attempt to improve neurological outcomes. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_6.


Assuntos
Hemodinâmica , Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia , Traumatismos da Coluna Vertebral/fisiopatologia
16.
Neurosurgery ; 84(1): E36-E38, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202962

RESUMO

QUESTION: Does the administration of a specific pharmacologic agent (eg, methylprednisolone) improve clinical outcomes in patients with thoracic and lumbar fractures and spinal cord injury? RECOMMENDATION: There is insufficient evidence to make a recommendation; however, the task force concluded, in light of previously published data and guidelines, that the complication profile should be carefully considered when deciding on the administration of methylprednisolone. Strength of recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_5.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/tratamento farmacológico , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Metilprednisolona/uso terapêutico , Fraturas da Coluna Vertebral/tratamento farmacológico , Fraturas da Coluna Vertebral/cirurgia
17.
Neurosurgery ; 84(1): 2-6, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202985

RESUMO

BACKGROUND: The thoracic and lumbar ("thoracolumbar") spine are the most commonly injured region of the spine in blunt trauma. Trauma of the thoracolumbar spine is frequently associated with spinal cord injury and other visceral and bony injuries. Prolonged pain and disability after thoracolumbar trauma present a significant burden on patients and society. OBJECTIVE: To formulate evidence-based clinical practice recommendations for the care of patients with injuries to the thoracolumbar spine. METHODS: A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to thoracolumbar spinal injuries based on specific clinically oriented questions. Relevant publications were selected for review. RESULTS: For all of the questions posed, the literature search yielded a total of 6561 abstracts. The task force selected 804 articles for full text review, and 78 were selected for inclusion in this overall systematic review. CONCLUSION: The available evidence for the evaluation and treatment of patients with thoracolumbar spine injuries demonstrates considerable heterogeneity and highly variable degrees of quality. However, the workgroup was able to formulate a number of key recommendations to guide clinical practice. Further research is needed to counter the relative paucity of evidence that specifically pertains to patients with only thoracolumbar spine injuries. The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.


Assuntos
Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/diagnóstico , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Medicina Baseada em Evidências , Humanos
18.
Neurosurgery ; 84(1): E28-E31, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30202989

RESUMO

BACKGROUND: Radiological evaluation of traumatic thoracolumbar fractures is used to classify the injury and determine the optimal treatment plan. Currently, there remains a lack of consensus regarding appropriate radiological protocol. Most clinicians use a combination of plain radiographs, 3-dimensional computed tomography with reconstructions, and magnetic resonance imaging (MRI). OBJECTIVE: To determine, through evidence-based guidelines review: (1) whether the use of MRI to identify ligamentous integrity predicted the need for surgical intervention; and (2) if there are any radiological findings that can assist in predicting clinical outcomes. METHODS: A systematic review of the literature was performed using the National Library of Medicine/PubMed database and the Cochrane Library for studies relevant to thoracolumbar trauma. Clinical studies specifically addressing the radiological evaluation of thoracolumbar spine trauma were selected for review. RESULTS: Two of 2278 studies met inclusion criteria for review. One retrospective review (Level III) and 1 prospective cohort (Level III) provided evidence that the addition of an MRI scan in acute thoracic and thoracolumbar trauma can predict the need for surgical intervention. There was insufficient evidence that MRI can help predict clinical outcomes in patients with acute traumatic thoracic and thoracolumbar spine injuries. CONCLUSION: This evidence-based guideline provides a Grade B recommendation that radiological findings in patients with acute thoracic or thoracolumbar spine trauma can predict the need for surgical intervention. This evidence-based guideline provides a grade insufficient recommendation that there is insufficient evidence to determine if radiographic findings can assist in predicting clinical outcomes in patients with acute thoracic and thoracolumbar spine injuries. QUESTION 1: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can predict the need for surgical intervention? RECOMMENDATION 1: Because MRI has been shown to influence the management of up to 25% of patients with thoracolumbar fractures, providers may use MRI to assess posterior ligamentous complex integrity, when determining the need for surgery. Strength of Recommendation: Grade B. QUESTION 2: Are there radiographic findings in patients with traumatic thoracolumbar fractures that can assist in predicting clinical outcomes? RECOMMENDATION 2: Due to a paucity of published studies, there is insufficient evidence that radiographic findings can be used as predictors of clinical outcomes in thoracolumbar fractures. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_3.


Assuntos
Vértebras Lombares/diagnóstico por imagem , Neurocirurgia/normas , Procedimentos Neurocirúrgicos/métodos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Processamento de Imagem Assistida por Computador , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética , Traumatismos da Coluna Vertebral/cirurgia , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X
19.
Neurosurgery ; 84(1): E50-E52, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203034

RESUMO

QUESTION 1: Does the surgical treatment of burst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 1: There is conflicting evidence to recommend for or against the use of surgical intervention to improve clinical outcomes in patients with thoracolumbar burst fracture who are neurologically intact. Therefore, it is recommended that the discretion of the treating provider be used to determine if the presenting thoracic or lumbar burst fracture in the neurologically intact patient warrants surgical intervention. Strength of Recommendation: Grade Insufficient. QUESTION 2: Does the surgical treatment of nonburst fractures of the thoracic and lumbar spine improve clinical outcomes compared to nonoperative treatment? RECOMMENDATION 2: There is insufficient evidence to recommend for or against the use of surgical intervention for nonburst thoracic or lumbar fractures. It is recommended that the decision to pursue surgery for such fractures be at the discretion of the treating physician. Strength of Recommendation: Grade Insufficient The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_1.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/cirurgia , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/terapia
20.
Neurosurgery ; 84(1): E39-E42, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30203078

RESUMO

QUESTION 1: Does routine screening for deep venous thrombosis prevent pulmonary embolism (or venous thromboembolism (VTE)-associated morbidity and mortality) in patients with thoracic and lumbar fractures? RECOMMENDATION 1: There is insufficient evidence to recommend for or against routine screening for deep venous thrombosis in preventing pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 2: For patients with thoracic and lumbar fractures, is one regimen of VTE prophylaxis superior to others with respect to prevention of pulmonary embolism (or VTE-associated morbidity and mortality)? RECOMMENDATION 2: There is insufficient evidence to recommend a specific regimen of VTE prophylaxis to prevent pulmonary embolism (or VTE-associated morbidity and mortality) in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. QUESTION 3: Is there a specific treatment regimen for documented VTE that provides fewer complications than other treatments in patients with thoracic and lumbar fractures? RECOMMENDATION 3: There is insufficient evidence to recommend for or against a specific treatment regimen for documented VTE that would provide fewer complications than other treatments in patients with thoracic and lumbar fractures. Strength of Recommendation: Grade Insufficient. RECOMMENDATION 4: Based on published data from pooled (cervical and thoracolumbar) spinal cord injury populations, the use of thromboprophylaxis is recommended to reduce the risk of VTE events in patients with thoracic and lumbar fractures. Consensus Statement by the Workgroup The full version of the guideline can be reviewed at: https://www.cns.org/guideline-chapters/congress-neurological-surgeons-systematic-review-evidence-based-guidelines/chapter_7.


Assuntos
Vértebras Lombares/lesões , Neurocirurgia/normas , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Tromboembolia/etiologia , Tromboembolia/terapia , Anticoagulantes/uso terapêutico , Medicina Baseada em Evidências , Guias como Assunto , Humanos , Traumatismos da Medula Espinal/complicações , Fraturas da Coluna Vertebral/complicações
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