Comparative analysis of patients with cauda equina syndrome versus an unaffected population undergoing spinal surgery.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To determine patient demographics, incidence of comorbidities, and procedure-related complications and identify risk factors associated with morbidity and mortality after spinal surgery for cauda equina syndrome (CES). SUMMARY OF BACKGROUND DATA: To our knowledge, no study has provided nationwide estimates of patient characteristics and procedure-related complication rates after spinal surgery for CES relative to an unaffected population. METHODS: Nationwide Inpatient Sample data collected between 2001 and 2010 were analyzed. Discharges with procedural codes for lumbar spinal fusion, decompression, or discectomy were included. The CES cohort included diagnoses of CES, and the unaffected cohort included lumbar spinal pathology diagnoses. Patient demographics, incidence of comorbidities and procedure-related complications, and risk factors associated with morbidity and mortality were compared. RESULTS: Discharges for 11,207 CES and 689,799 unaffected patients were identified. Differences between cohorts were found for demographic and hospital data. Average comorbidity indices for the CES cohort were found to be increased (0.23 vs. 0.13, P < 0.0001), as well as the incidence of total procedure-related complications (18.63% vs. 13.12%, P < 0.0001). In-hospital mortality rate was significantly increased for the CES cohort (0.30% vs. 0.08%, P < 0.0001). A number of comorbidities associated with additional risk for morbidity and mortality among the CES cohort were identified. CONCLUSION: Relative to an unaffected population undergoing similar treatment, patients with CES were more likely to have increased associated comorbidities on presentation, as well as increased complication rates with a prolonged hospital course postoperatively. CES was found to carry an increased incidence of procedure-related complications as well as in-hospital mortality. A number of comorbidities associated with additional risk for morbidity and mortality among the CES cohort were identified. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality as well as direct future research to improve patient outcomes. LEVEL OF EVIDENCE: 3.

[Surgical management of vertebral column metastatic disease]. / Chirurgisches Management von Wirbelsäulenmetastasen.

The spine is the most frequent site of skeletal metastases. Among all spinal malignancies metastatic disease is most frequent and indicative of disseminating tumor disease. Depending on primary tumor entity, estimated survival time, general health status of the patient, presence of spinal instability and neurological deficits an oncological useful and patient-specific therapeutic intervention should be performed. New anterior approaches, resections and reconstruction techniques are making surgery a preferred method over radiation therapy. For differential indication of the multiple surgical treatment modalities prognostic scores are available to assist individual decision making. Indications for surgery include survival prognosis of minimum 3 months, intractable pain, progress of myelon compression and/or neurological deficits under radiochemotherapy, spinal instability and necessity for histological diagnosis. Resulting quality of life depends on efficient decompression of the spinal cord and restoration of spinal stability. To achieve these ultimate goals there are different anterior and posterior approaches, instrumentations and vertebral body replacement implants available. Preoperative embolization should be performed in hypervascular tumors, e.g., renal cell cancer. Vertebro-/Kyphoplasty as a percutaneous intervention should be considered for painful multisegmental disease and symptomatic osteolysis without epidural tumor compression to reach analgesia and stability. A multidisciplinary approach in patient selection, decision making and management is an essential precondition for complication avoidance and acceptable quality of life.

Chondroblastoma of the lumbar spine with cauda equina syndrome.

STUDY DESIGN: Case report. OBJECTIVE: To describe the clinical presentations, radiological features and clinical progress of a rare case of chondroblastoma of the lumbar spine. SETTING: Regional Hospital, Hong Kong, China. METHOD: A 54-year-old male patient presented with low back pain and left sciatica. X-ray and MRI revealed tumour infiltration of the fifth lumbar vertebrae and left paraspinal muscles, which was found to be a chondroblastoma by repeated open biopsies. The tumour was removed surgically by combined anterior and posterior approaches, followed by spinal fusion and instrumentation. RESULTS: The anterior tricortical bone graft was complicated with fracture and nonunion. Surgical re-exploration confirmed local recurrence of tumour macroscopically and histologically. The patient developed symptoms and signs of cauda equina syndrome gradually despite repeated surgery and irradiation. The patient eventually died of complications of local recurrence and neurological deficit at 3 years and 8 months after the first operation. CONCLUSION: This is the first case report of chondroblastoma of the lumbar spine. The clinical profile of this patient and the evidence from the literature review suggests that spinal chondroblastoma has a very aggressive behaviour with high recurrence and mortality rate.

Guillain-Barré syndrome in Greater New York-New Jersey.

Epidemiologic data on 176 patients with acute Guillain-Barré syndrome observed over a nine-year period in the New York-New Jersey metropolitan area are presented. A striking predilection for patients aged 16 to 25 years, with a second lesser peak between ages 45 to 60, was found. Seasonal clustering of patients occurred, with nearly half the patients afflicted during the four-month period of late summer and fall. The distribution between men and women was equal. In this series 23% of the patients required tracheostomy, and 5% had a fatal course.

The role of intensive care units.

The indications for intensive care are discussed. Selection of patients should be based upon the apparent reversibility of disease processes and the likelihood of producing worthwhile relief of suffering. Admission statistics for one II-bed unit are also presented, and survival rates exceeding 90% of three "model" conditions-namely, fat embolism, tetanus and Gullain-Barré syndrome-are reported. The hospital costs for treating critically ill patients are approximately three times those for treating the "average" patient.

Cellular hypersensitization to peripheral nervous antigens in the Guillain-Barré syndrome.

The macrophage migration inhibition factor assay was used as a specific measure of cellular hypersensitivity to peripheral nervous system antigen in a large group of Guillain-Barre patients and control subjects. Lymphocytes from 34 patients with Guillain-Barre syndrome, 33 with other peripheral nervous system disease, and 33 normal controls were assayed for production of macrophage migration inhibition factor. A mean of 101 +/- 7.2 was obtained in the control group, 70 +/- 16.3 in the Guillain-Barre syndrome group, and 96 +/- 11.3 in those with other peripheral nervous system disease. Twenty-six of the 34 patients with Guillain-Barre syndrome, two patients with myeloradiculitis, and two with Bell's palsy gave significant values. These results support the hypothesis that cellular hypersensitization to peripheral nervous system antigens is a pathogenetic factor in Guillain-Barre syndrome.