Mobile health supported multi-domain recovery trajectories after major arthroplasty or spine surgery: a pilot feasibility and usability study.

BACKGROUND: Recovery after surgery intersects physical, psychological, and social domains. In this study we aim to assess the feasibility and usability of a mobile health application called PositiveTrends to track recovery in these domains amongst participants undergoing hip, knee arthroplasty or spine surgery. Our secondary aim was to generate procedure-specific, recovery trajectories within the pain and medication, psycho-social and patient-reported outcomes domain. METHODS: Prospective, observational study in participants greater than eighteen years of age. Data was collected prior to and up to one hundred and eighty days after completion of surgery within the three domains using PositiveTrends. Feasibility was assessed using participant response rates from the PositiveTrends app. Usability was assessed quantitatively using the System Usability Scale. Heat maps and effect plots were used to visualize multi-domain recovery trajectories. Generalized linear mixed effects models were used to estimate the change in the outcomes over time. RESULTS: Forty-two participants were enrolled over a four-month recruitment period. Proportion of app responses was highest for participants who underwent spine surgery (median = 78, range = 36-100), followed by those who underwent knee arthroplasty (median = 72, range = 12-100), and hip arthroplasty (median = 62, range = 12-98). System Usability Scale mean score was 82 ± 16 at 180 days postoperatively. Function improved by 8 and 6.4 points per month after hip and knee arthroplasty, respectively. In spine participants, the Oswestry Disability Index decreased by 1.4 points per month. Mood improved in all three cohorts, however stress levels remained elevated in spine participants. Pain decreased by 0.16 (95% Confidence Interval: 0.13-0.20, p < 0.001), 0.25 (95% CI: 0.21-0.28, p < 0.001) and 0.14 (95% CI: 0.12-0.15, p < 0.001) points per month in hip, knee, and spine cohorts respectively. There was a 10.9-to-40.3-fold increase in the probability of using no medication for each month postoperatively. CONCLUSIONS: In this study, we demonstrate the feasibility and usability of PositiveTrends, which can map and track multi-domain recovery trajectories after major arthroplasty or spine surgery.

Clinical characteristics and long-term outcomes for patients who undergo cytoreductive surgery for thoracic meningiomas: a retrospective analysis.

OBJECTIVE: Primary spinal meningiomas represent a rare indolent neoplasm usually situated in the intradural-extramedullary compartment. They have a predilection for afflicting the thoracic spine and most frequently present with sensory and/or motor symptoms. Resection is the first-line treatment for symptomatic tumors, whereas other clinical factors will determine the need for adjuvant therapy. In this study, the authors aimed to elucidate clinical presentation, functional outcomes, and long-term outcomes in this population in order to better equip clinicians with the tools to counsel their patients. METHODS: This is a retrospective analysis of patients treated at the authors' institution between 1998 and 2018. All patients with thoracic meningiomas who underwent resection and completed at least one follow-up appointment were included. Multiple preoperative clinical variables, hospitalization details, and long-term outcomes were collected for the cohort. RESULTS: Forty-six patients who underwent resection for thoracic meningiomas were included. The average age of the cohort was 59 years, and the median follow-up was 53 months. Persistent sensory and motor symptoms were present in 29 patients (63%). Fifteen lesions were ventrally positioned. There were 43 WHO grade I tumors, 2 WHO grade II tumors, and 1 WHO grade III tumor; the grade III tumor was the only case of recurrence. The median length of hospitalization was 4 days. Seventeen patients (37%) were discharged to rehabilitation facilities. Thirty patients (65.2%) experienced resolution or improvement of symptoms, and there were no deaths within 30 days of surgery. Only 1 patient developed painful kyphosis and was managed medically. Ventral tumor position, new postoperative deficits, and length of stay did not correlate with disposition to a facility. Age, ventral position, blood loss, and increasing WHO grade did not correlate with length of stay. CONCLUSIONS: Outcomes are overall favorable for patients who undergo resection of thoracic meningiomas. Symptomatic patients often experience improvement, and patients generally do not require significant future operations. Tumors located ventrally, while anatomically challenging, do not necessarily herald a significantly worse prognosis or limit the extent of resection.

Mini-open lateral retropleural/retroperitoneal approaches for thoracic and thoracolumbar junction anterior column pathologies.

OBJECTIVE: Advancements in less invasive lateral retropleural/retroperitoneal approaches aim to address the limitation of posterolateral approaches and avoid complications associated with anterior open thoracotomy or thoracoabdominal approaches. METHODS: Consecutive patients treated with a mini-open lateral approach for thoracic or thoracolumbar anterior column pathologies were analyzed in a retrospective case series including clinical and radiographic outcomes. Special attention is given to operative techniques and surgical nuances. RESULTS: Eleven patients underwent a mini-open lateral retropleural or combined retropleural/retroperitoneal approach for thoracic or thoracolumbar junction lesions. Surgical indications included chronic fracture/deformity (n = 5), acute fracture (n = 2), neoplasm (n = 2), and osteomyelitis (n = 2). The mean length of postoperative hospital stay was 7.2 days (range 2-19 days). All patients ultimately had successful decompression and reconstruction with a mean follow-up of 16.7 months (range 6-29 months). Axial back pain assessed by the visual analog scale improved from a mean score of 8.2 to 2.2. Complications included 1 patient with deep venous thrombosis and pulmonary embolism and 1 with pneumonia. One patient developed increased leg weakness, which subsequently improved. One patient undergoing corpectomy with only lateral plate fixation developed cage subsidence requiring posterior stabilization. CONCLUSIONS: Mini-open lateral retropleural and retroperitoneal corpectomies can safely achieve anterior column reconstruction and spinal deformity correction for various thoracic and thoracolumbar vertebral pathologies.

Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study.

OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (ß = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: ß = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: ß = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.

Brainstem metastases treated with stereotactic radiosurgery: safety, efficacy, and dose response.

The safety and efficacy of stereotactic radiosurgery (SRS) in the brainstem is questioned by some over concern of violating historical brainstem SRS dose tolerance. Our purpose was to report on the clinical outcomes of patients treated at our institution with radiosurgery for brainstem metastases. Patients with metastatic tumors within or directly abutting the brainstem from 1992 to 2014 were analyzed. Patient and tumor characteristics, SRS parameters, and toxicity were recorded and analyzed for associations with local control and survival. Multivariate statistical analysis was performed using Cox proportional hazards modeling. One-hundred and eighty-nine (189) brainstem metastases from 161 patients were included in our analysis. Whole brain irradiation was administered prior to SRS in 52 % of patients. The median margin dose was 18 Gy prescribed to the 50 % isodose line. Median imaging follow up was 5.4 months and median survival was 5.5 months after SRS. At last follow up, local control was achieved in 87.3 % of brainstem lesions treated. There were 3 recorded events of grade 3-5 toxicity (1.8 %). On multivariate analysis, a margin dose ≥16 Gy was associated with improved local control (p = 0.049) and greater KPS score was associated with improved overall survival following SRS (p = 0.024). Patients with brainstem metastases who have limited intracranial disease and/or who have received whole brain irradiation should be considered for SRS. Margin doses of at least 16 Gy are associated with superior local control, and serious radiation toxicity in SRS for brainstem metastasis appears rare.

Effect of prior hemorrhage on intracranial arteriovenous malformation radiosurgery outcomes.

BACKGROUND: Intracerebral hemorrhage is simultaneously the most frequent and most debilitating manifestation of intracranial arteriovenous malformations (AVM), but its impact on success and complications of radiosurgery has not been rigorously assessed. In this case-control study, we define the effect of prior hemorrhage on AVM radiosurgery outcomes. METHODS: From a prospective, institutional database of 1,400 AVM patients treated with Gamma Knife radiosurgery, unruptured and ruptured AVMs were matched in a 1:1 fashion, blinded to outcome, based on patient demographics, prior embolization (26.6% of each cohort), AVM size (mean volume of unruptured AVMs 3.7 cm(3) versus ruptured AVMs 3.5 cm(3), p = 0.195), Spetzler-Martin grade (Grade I 17.0%, Grade II 37.8%, Grade III 34.8%, Grade IV 10.4% for each cohort), and radiosurgical treatment parameters (mean prescription dose for unruptured AVMs 20.9 Gy versus ruptured AVMs 21.0 Gy, p = 0.837). There were 270 patients in each cohort. Matched statistical analyses were used to compare the baseline characteristics, obliteration rates, post-radiosurgery latency period hemorrhage risks, and incidences of radiation-induced changes (RIC) between the two cohorts. RESULTS: The actuarial obliteration rates of the two cohorts were similar (unruptured AVMs: 38, 58, and 76% at 3, 5, 10 years, respectively; ruptured AVMs: 40, 60, and 73% at 3, 5, 10 years, respectively; p = 0.592). However, for embolized AVMs, complete obliteration was more likely to be achieved in unruptured lesions (unruptured AVMs: 25, 32, and 54% at 3, 5, 10 years, respectively; ruptured AVMs: 18, 27, and 42% at 3, 5, 10 years, respectively; p = 0.038). Prior AVM rupture resulted in a higher annual risk of post-radiosurgery latency period hemorrhage (ruptured AVMs 2.3% versus unruptured AVMs 1.1%, p = 0.025) but a lower rate of cumulative and symptomatic RIC (cumulative RIC: ruptured AVMs 30.4% versus unruptured AVMs 48.9%, p < 0.0001; symptomatic RIC: ruptured AVMs 7.0% versus unruptured AVMs 12.2%, p = 0.041, respectively). The rates of permanent RIC were similar between the unruptured (2.2%) and ruptured (1.9%) AVM cohorts (p = 0.761). The mean time interval to onset of RIC (unruptured AVMs 13.3 months versus ruptured AVMs 12.1 months, p = 0.783), and the mean duration of RIC (unruptured AVMs 22.0 months versus ruptured AVMs 21.7 months, p = 0.599) were not significantly different between the two cohorts. CONCLUSIONS: Prior AVM rupture significantly alters the risk of latency period hemorrhage and RIC following radiosurgery. These effects should be taken into consideration with the multidisciplinary management of AVM patients. Radiosurgery does not significantly alter the natural history of the hemorrhage risks of unruptured and ruptured AVMs unless obliteration is achieved.

Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients.

BACKGROUND: Unruptured cerebral arteriovenous malformations (AVMs) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs (ARUBA). Therefore, the efficacy of radiosurgery for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following radiosurgery for unruptured AVMs in pediatric patients. METHODS: We evaluated a prospective database, from 1989 to 2013, of AVM patients treated with radiosurgery at our institution. Patients with age less than 18 years at the time of radiosurgery, unruptured nidi, and at least 2 years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. RESULTS: In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure in 53 %. The median nidus volume and radiosurgical margin dose were 3.2 cm(3) and 21.5 Gy, respectively. The median radiologic follow-up was 45 months. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29 %, 54 %, and 72 %, respectively. In the multivariate Cox proportional hazards regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. Obliteration rates were significantly higher with a margin dose of at least 22 Gy (P = 0.003) and for nidi with 2 or fewer draining veins (P = 0.001). The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55 %, 16 %, and 2 %, respectively. The annual post-radiosurgery hemorrhage rate was 1.3 %, and the incidence of post-radiosurgery cyst formation was 2 %. CONCLUSION: Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach.

Unyielding progress: recent advances in the treatment of central nervous system neoplasms with radiosurgery and radiation therapy.

In the past decade, our understanding of the roles of external beam radiotherapy (EBRT) and stereotactic radiosurgery (SRS) in the management of brain tumors has dramatically improved. To highlight the changes and contemporary treatment approaches, we review the indications and outcomes of ionizing radiation for benign intracranial tumors and brain metastases. For nonfunctioning pituitary adenomas, SRS is able to achieve radiographic tumor control in at least 90 % of cases. The rate of SRS-induced endocrine remission for functioning pituitary adenomas depends on the tumor subtype, but it is generally lower than the rate of radiographic tumor control. The most common complications from pituitary adenoma SRS treatment are hypopituitarism and cranial neuropathies. SRS has become the preferred treatment modality for vestibular schwannomas and skull base meningiomas less than 3 cm in size. Large vestibular schwannomas and meningiomas remain best managed with initial surgical resection or EBRT for surgically ineligible patients. For small to moderately sized brain metastases, there has been a shift toward treatment of newly diagnosed patients with SRS alone due to similar local control rates compared with surgical resection. RCTs have shown combined SRS and whole brain radiation therapy (WBRT) for brain metastases to decrease rates of local and distant intracranial recurrence compared to SRS alone. However, the improved intracranial control comes at the expense of poorer neurocognitive outcomes and without prolonging overall survival. Therefore, WBRT is generally reserved for salvage therapy. While EBRT has been frequently supplanted by SRS for the treatment pituitary adenomas and brain metastases, it still proves useful in selected cases of large lesions which are not amenable to surgical debulking or for those with widespread disease, poor performance status, and short life expectancy. In recent years, the scope of SRS has extended beyond the intracranial space to include extradural and intradural spinal tumors.

Application of diffusion-weighted magnetic resonance imaging to predict the intracranial metastatic tumor response to gamma knife radiosurgery.

To evaluate the effect of stereotactic radiosurgery (SRS) on intracranial metastases with diffusion-weighted imaging/apparent diffusion coefficient maps. A total of 107 patients with 144 metastases larger than 1 cm in diameter were retrospectively reviewed. We calculated the DWI(Tumor/white matter) ratios (DWI(T/WM) ratio) between the metastases and the normal, contralateral frontal white matter at each time point. We also recorded the ADC values for metastases (ADCT values). The DWI(T/WM) ratio and ADCT values were assessed for correlation with the patients' tumor response, brain edema, and survival. A decrease in DWI(T/WM) ratios was seen in the controlled metastases, and an increase in the DWI(T/WM) ratio were seen in the metastases with poor tumor control. On the other hand, an increase in ADCT values was seen in the controlled metastases, and a decrease in ADCT values was seen in the metastases with poor control. The differences were significant (p value: 0.001 and 0.002, respectively). Sensitivity of a decrease in the DWI(T/WM) ratio to make an early prediction of tumor control was 83.9%, and specificity was 88.5%. When using the initial ADCT values of metastases to predict tumor response, sensitivity and specificity were 85.5 and 72.7%, respectively. DWI/ADC is a practical method for studying the efficacy of SRS and predicting early metastases response progression. A decrease signal on DWI and increased ADC values are indicators of good tumor control, and reflect the beneficial effect of SRS.

Seizure outcomes following radiosurgery for cerebral arteriovenous malformations.

OBJECT: Seizures are a common presentation of cerebral arteriovenous malformations (AVMs). The authors evaluated the efficacy of stereotactic radiosurgery (SRS) for the management of seizures associated with AVMs and identified factors influencing seizure outcomes following SRS for AVMs. METHODS: A systematic literature review was performed using PubMed. Studies selected for review were published in English, included at least 5 patients with both cerebral AVMs and presenting seizures treated with SRS, and provided post-SRS outcome data regarding obliteration of AVMs and/or seizures. Demographic, radiosurgical, radiological, and seizure outcome data were extracted and analyzed. All seizure outcomes were categorized as follows: 1) seizure free, 2) seizure improvement, 3) seizure unchanged, and 4) seizure worsened. Systematic statistical analysis was conducted to assess the effect of post-SRS AVM obliteration on seizure outcome. RESULTS: Nineteen case series with a total of 3971 AVM patients were included for analysis. Of these, 28% of patients presented with seizures, and data for 997 patients with available seizure outcome data who met the inclusion criteria were evaluated. Of these, 437 (43.8%) patients achieved seizure-free status after SRS, and 530 (68.7%) of 771 patients with available data achieved seizure control (seizure freedom or seizure improvement) following SRS. Factors associated with improved seizure outcomes following SRS for AVMs were analyzed in 9 studies. Seizure-free status was achieved in 82% and 41.0% of patients with complete and incomplete AVM obliteration, respectively. Complete AVM obliteration offered superior seizure-free rates compared with incomplete AVM obliteration (OR 6.13; 95% CI 2.16-17.44; p = 0.0007). CONCLUSIONS: Stereotactic radiosurgery offers favorable seizure outcomes for AVM patients presenting with seizures. Improved seizure control is significantly more likely with complete AVM obliteration.

Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations.

OBJECT: The aim in this paper was to compare the outcomes of dose-staged and volume-staged stereotactic radio-surgery (SRS) in the treatment of large (> 10 cm(3)) arteriovenous malformations (AVMs). METHODS: A systematic literature review was performed using PubMed. Studies written in the English language with at least 5 patients harboring large (> 10 cm(3)) AVMs treated with dose- or volume-staged SRS that reported post-treatment outcomes data were selected for review. Demographic information, radiosurgical treatment parameters, and post-SRS outcomes and complications were analyzed for each of these studies. RESULTS: The mean complete obliteration rates for the dose- and volume-staged groups were 22.8% and 47.5%, respectively. Complete obliteration was demonstrated in 30 of 161 (18.6%) and 59 of 120 (49.2%) patients in the dose- and volume-staged groups, respectively. The mean rates of symptomatic radiation-induced changes were 13.5% and 13.6% in dose- and volume-staged groups, respectively. The mean rates of cumulative post-SRS latency period hemorrhage were 12.3% and 17.8% in the dose- and volume-staged groups, respectively. The mean rates of post-SRS mortality were 3.2% and 4.6% in dose- and volume-staged groups, respectively. CONCLUSIONS: Volume-staged SRS affords higher obliteration rates and similar complication rates compared with dose-staged SRS. Thus, volume-staged SRS may be a superior approach for large AVMs that are not amenable to single-session SRS. Staged radiosurgery should be considered as an efficacious component of multimodality AVM management.

Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations.

INTRODUCTION: The management of Spetzler-Martin Grade-IV and -V arteriovenous malformations (AVMs) is controversial due to their uncertain natural history, the high rate of morbidity and mortality associated with microsurgical resection, and the relatively low rate of successful obliteration from less invasive approaches such as radiosurgery and embolization. We present our radiosurgical results for high-grade AVMs. METHODS: We identified all patients with Spetzler-Martin Grade-IV and -V AVMs treated with single-session radiosurgery at the University of Virginia between 1989 and 2009. Patients with less than 2 years of follow-up without obliteration were excluded. This yielded 110 patients with a median age 27.6 years. The median AVM volume was 5.7 cc and prescription dose was 19 Gy. The median radiographic and clinical follow-up intervals were 88 and 97 months, respectively. RESULTS: Complete AVM obliteration was identified on MRI only in 11 patients (10%) and confirmed by DSA in 38 patients (34%) for a cumulative obliteration rate of 44%. The actuarial rates of obliteration at 3 and 5 years were 10% and 23%, respectively. The mean and median times to obliteration were 60 months and 43 months, respectively. Significant independent predictors of obliteration were no pre-radiosurgery embolization (P = 0.008), superficial location (P = 0.001), and higher prescription dose (P = 0.028). The annual rate of post-radiosurgery hemorrhage was 3.0%, and symptomatic RIC was observed in 12% of patients. Unruptured AVMs were more likely to have RIC (P = 0.005). The rates of temporary and permanent post-radiosurgery clinical deterioration were 9% and 10%, respectively. CONCLUSION: Single-session radiosurgery is an acceptable treatment option for select patients harboring high-grade AVMs for which microsurgery or conservative management are associated with an unacceptably high risk of adverse outcomes.

Use of Patient-Specific Interbody Cages Through a Minimally Invasive Lateral Approach for Unstable Lumbar Spondylodiskitis.

BACKGROUND AND OBJECTIVES: Patients with diskitis/osteomyelitis who do not respond to medical treatment or develop spinal instability/deformity may warrant surgical intervention. Irregular bony destruction due to the infection can pose a challenge for spinal reconstruction. The authors report a lateral approach using patient-specific interbody cages combined with posterior or lateral instrumentation to achieve spinal reconstruction for spinal instability/deformity from spondylodiskitis. METHODS: This is a retrospective review of 4 cases undergoing debridement, lateral lumbar interbody fusion using patient-specific interbody cages, and supplemental lateral or posterior instrumentation for spinal instability/deformity after spondylodiskitis. The surgical technique is reported, as are the clinical and imaging outcomes. RESULTS: Four male patients with a mean age of 69 years comprised this study. One had lateral lumbar interbody fusion at L2/3 and 3 at L4/5. The mean hospital stay was 5.8 days. The mean follow-up was 8.5 months (range 6-12 months). There were no approach-related neurological injuries or complications. The mean visual analog scale back pain scores improved from 9.5 to 1.5, and the mean Oswestry disability index improved from 68.5 to 23 at the end of the follow-up. The mean lumbar lordosis increased from 18° to 51°. The segmental angle increased from 6.5° to 18°. The coronal shift was 2.8 cm preoperatively and 0.9 cm postoperatively. The coronal Cobb angle reduced from 8.8° preoperatively to 2.8° postoperatively. On postoperative computed tomography, all patients had interval development of bridging bone across the surgical level through or around the cage. None of them developed cage migration or subsidence. CONCLUSION: Patients with irregular bony destruction due to diskitis/osteomyelitis may benefit from patient-specific cages for spinal reconstruction to address spinal instability and deformity.

Novel method of iliac accessory rods for rod fracture prevention in adult deformity surgery: a case series of 82 patients with outcomes and complications.

OBJECTIVE: Primary rod fracture after surgery for adult spinal deformity (ASD) is a leading cause of revision, with recent prospective multicenter fracture rates reported at 11%-14% by 2 years. Consequently, the addition of supplemental rods has been explored to reduce fractures. Here the authors describe their experience with a novel iliac accessory rod technique in which each accessory rod anchors to an independent iliac bolt caudally via lateral connector, and attaches to the primary rod rostrally via side-to-side connector. METHODS: This retrospective, single-center case series included patients who underwent thoracolumbar/lumbar fusion for ASD between March 2019 and August 2023. Data on baseline demographics, radiographic parameters, surgical characteristics, complications, rod fracture, and revision rates were collected. Paired, 2-tailed t-tests were used to compare pre- and postoperative radiographic outcomes. Rod fracture rates were compared to prior investigations via chi-square goodness of fit testing. The technique for iliac accessory rod placement is described. RESULTS: The study consisted of 82 patients (mean age 66 years, 51% female, 26% with prior fusion) with a median follow-up of 2 years (IQR 28-104 weeks). A total of 50 patients (61%) had ≥ 2-year follow-up. Each surgery involved an average of 4 posterior column osteotomies and 8 segments. Iliac accessory rods were cobalt chromium and were placed bilaterally in 87% of constructs. Postoperative alignment improved significantly in the following parameters: maximum coronal Cobb angle, fractional curve, sagittal vertical axis, lumbar lordosis, thoracic kyphosis, and pelvic incidence to lumbar lordosis mismatch (p < 0.001 for all comparisons). Of 50 patients with ≥ 2-year follow-up, rod fracture occurred in 1 (2.0%), which was incidentally found and required no intervention. The present rod fracture rate was significantly lower than the authors' historically reported institutional rate of 21% for traditional dual-rod constructs, and the 11%-14% reported in recent prospective multicenter studies that used traditional and supplemental rod constructs (p < 0.05 for all comparisons). Reoperation occurred in 12 patients (14.6%); 7 (8.5%) for proximal junctional kyphosis and 5 (6.1%) for wound complication. CONCLUSIONS: Here the authors describe their experience with a novel iliac accessory rod technique to prevent rod fracture in patients undergoing surgery for ASD. The 2-year rod fracture rate (2.0%) in this study is significantly lower than the authors' historical dual-rod fracture rate, and other prospective multicenter investigations. Future studies with longer follow-up are needed to determine the durability of this technique.

Iliac Accessory Rod Technique for Rod Fracture Prevention in Long Fusion Constructs: 2-Dimensional Operative Video.

Implant-related complications in surgery for adult spinal deformity (ASD) account for roughly $1 billion US health care expenditures over 5 years, with a majority due to primary rod fracture.1,2 Traditional two-rod constructs have demonstrated rod fracture rates of up to 40%, with a median time to fracture of 3 years.3 Current supplementary rod techniques for decreasing rod fractures inadequately address the issue of increased strain across the lumbosacral junction.4 Here, we describe a novel four-rod technique using "iliac accessory rods," designed to mitigate rod fractures by reinforcing osteotomy levels and dispersing biomechanical stress across the lumbosacral junction. Compared with other supplementary rod techniques for ASD, iliac accessory rods anchor to independent iliac bolts.5 The added fixation points across the lumbosacral junction (4 iliac bolts total) substantially offloads stress on primary rods, most of which fracture near the lumbosacral junction.3 Additionally, connecting these rods to primary rods rostrally via side-to-side connectors, above the osteotomy levels, ensures mobile osteotomy segments are reinforced. Presented is a 78-year-old woman with ASD and worsening lower back pain, radiculopathy, and bilateral leg weakness who failed nonoperative management. She underwent T9 to bi-iliac instrumented fusion with L1-S1 posterior column osteotomies, L4-S1 transforaminal lumbar interbody fusions, and bilateral iliac accessory rod fixation. Postoperatively, she recovered well and had improvement in her symptoms. Imaging revealed correction of spinal alignment. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image. Institutional Review Board approval was waived because of institutional exemption policy.

Reliability of a Novel Classification System for Thoracic Disc Herniations.

STUDY DESIGN: This is a cross-sectional survey. OBJECTIVE: The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA: TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS: Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS: High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS: This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.

The role of radiosurgery in the management of WHO Grade II and III intracranial meningiomas.

OBJECT: WHO Grade II and III intracranial meningiomas are uncommon, but they portend a significantly worse prognosis than their benign Grade I counterparts. The mainstay of current management is resection to obtain cytoreduction and histological tissue diagnosis. The timing and benefit of postoperative fractionated external beam radiation therapy and stereotactic radiosurgery remain controversial. The authors review the stereotactic radiosurgery outcomes for Grade II and III meningiomas. METHODS: A comprehensive literature search was performed using PubMed to identify all radiosurgery series reporting the treatment outcomes for Grade II and III meningiomas. Case reports and case series involving fewer than 10 patients were excluded. RESULTS: From 1998 to 2013, 19 radiosurgery series were published in which 647 Grade II and III meningiomas were treated. Median tumor volumes were 2.2-14.6 cm(3). The median margin doses were 14-21 Gy, although generally the margin doses for Grade II meningiomas were 16-20 Gy and the margin doses for Grade III meningiomas were 18-22 Gy. The median 5-year PFS was 59% for Grade II tumors and 13% for Grade III tumors, which may have been affected by patient age, prior radiation therapy, tumor volume, and radiosurgical dose and timing. The median complication rate following radiosurgery was 8%. CONCLUSIONS: The current data for radiosurgery suggest that it has a role in the management of residual or recurrent Grade II and III meningiomas. However, better studies are needed to fully define this role. Due to the relatively low prevalence of these tumors, it is unlikely that prospective studies will be feasible. As such, well-designed retrospective analyses may improve our understanding of the effect of radiosurgery on tumor recurrence and patient survival and the incidence and impact of treatment-induced complications.

Use of Tethers for Proximal Junctional Kyphosis Prophylaxis in Adult Spinal Deformity Surgery: A Review of Current Clinical Evidence.

BACKGROUND: Surgery for adult spinal deformity (ASD) often involves long-segment posterior instrumentation that introduces stress at the proximal junction that can result in proximal junctional kyphosis (PJK) or proximal junctional failure (PJF). Recently, the use of tethers at the proximal junction has been proposed as a means of buffering the transitional stresses and reducing the risk of PJK/PJF. Our objectives are to summarize the clinical literature on proximal junctional tethers for PJK/PJF prophylaxis. METHODS: Articles published between 1 January 2000 and 10 November 2022 were identified via a PubMed search using combinations of the search terms "spine surgery," "ASD," "complication," "surgery," "PJK," "PJF," "tether," "sublaminar band," and "prophylaxis." No restrictions were placed on the number of patients, surgical indications, or surgical procedures. Relevant articles were reviewed and summarized. RESULTS: Fifteen articles were identified, including 2 prospective cohorts (Level II), 10 retrospective cohorts (Level III), and 3 retrospective case series (Level IV). All studies were published between 2016 and 2022, and all focused on ASD patient populations. The mean age in each study ranged from 55 to 69 years, and most studies had a mean follow-up of at least 12 months (range, 5.5-45.4 months). Eleven studies used a polyethylene tether, 2 used soft sublaminar cables, and 2 used semitendinous allograft. The tether extended to the UIV+1 or UIV+2, passing either through or around the spinous processes, in 13 studies. In the remaining 2 studies, the tether was passed sublaminar at the UIV+1. Fourteen studies favored the use of tethers with regard to reduction of PJK/PJF rates, and one demonstrated similar rates of PJK between the tether and no-tether groups. CONCLUSIONS: PJK/PJF remain major challenges in ASD surgery. Most early studies suggest that the use of tethers for ligamentous augmentation may help to mitigate the development of PJK/PJF. However, the multifactorial etiology of PJK/PJF makes it unlikely that any single technique will solve this complex problem. Further study is needed to address not only the effectiveness of junctional tethers but also to clarify whether there are optimal tether configurations, tether materials, and tether tension. LEVEL EVIDENCE: 3.

Rod fractures in thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis: long-term follow-up of a prospective, multicenter cohort of 160 patients.

OBJECTIVE: Previous reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up. METHODS: Patient records were obtained from the Adult Symptomatic Lumbar Scoliosis-1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40-80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery. RESULTS: Inclusion criteria were met by 160 patients (median age 62 years, IQR 55.7-67.9 years). At a median follow-up of 5.1 years (IQR 3.8-6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9-4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196-3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005-1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8-6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18-0.84, p = 0.016). CONCLUSIONS: This study provides what is to the authors' knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.

Proximal junctional failure in primary thoracolumbar fusion/fixation to the sacrum/pelvis for adult symptomatic lumbar scoliosis: long-term follow-up of a prospective multicenter cohort of 160 patients.

OBJECTIVE: Proximal junctional failure (PJF) is a severe form of proximal junctional kyphosis. Previous reports on PJF have been limited by heterogeneous cohorts and relatively short follow-ups. The authors' objectives herein were to identify risk factors for PJF and to assess its long-term incidence and revision rates in a homogeneous cohort. METHODS: The authors reviewed data from the Adult Symptomatic Lumbar Scoliosis 1 trial (ASLS-1), a National Institutes of Health-sponsored prospective multicenter study. Inclusion criteria were an age ≥ 40 years, ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society revised 22-item questionnaire [SRS-22r] score ≤ 4.0 in pain, function, or self-image domains), and primary thoracolumbar fusion/fixation to the sacrum/pelvis of ≥ 7 levels. PJF was defined as a postoperative proximal junctional angle (PJA) change > 20°, fracture of the uppermost instrumented vertebra (UIV) or UIV+1 with > 20% vertebral height loss, spondylolisthesis of UIV/UIV+1 > 3 mm, or UIV screw dislodgment. RESULTS: One hundred sixty patients (141 women) were included in this analysis and had a median age of 62 years and a mean follow-up of 4.3 years (range 0.1-6.1 years). Forty-six patients (28.8%) had PJF at a median of 0.92 years (IQR 0.14, 1.23 years) following surgery. Based on Kaplan-Meier analyses, PJF rates at 1, 2, 3, and 4 years were 14.4%, 21.9%, 25.9%, and 27.4%, respectively. On univariate analysis, PJF was associated with greater age (p = 0.0316), greater body mass index (BMI; p = 0.0319), worse baseline patient-reported outcome measures (PROMs; ODI, SRS-22r, and SF-12 Physical Component Summary [PCS]; all p < 0.04), the use of posterior column osteotomies (PCOs; p = 0.0039), and greater postoperative thoracic kyphosis (TK; p = 0.0031) and PJA (p < 0.001). The use of UIV hooks was protective against PJF (p = 0.0340). On regression analysis (without postoperative measures), PJF was associated with greater BMI (HR 1.077, 95% CI 1.007-1.153, p = 0.0317), lower preoperative PJA (HR 0.607, 95% CI 0.407-0.906, p = 0.0146), and greater preoperative TK (HR 1.362, 95% CI 1.082-1.715, p = 0.0085). Patients with PJF had worse PROMs at the last follow-up (ODI, SRS-22r subscore and self-image, and SF-12 PCS; p < 0.04). Sixteen PJF patients (34.8%) underwent revision, and PJF recurred in 3 (18.8%). CONCLUSIONS: Among 160 primary ASLS patients with a median age of 62 years and predominant coronal deformity, the PJF rate was 28.8% at a mean 4.3-year follow-up, with a revision rate of 34.8%. On univariate analysis, PJF was associated with a greater age and BMI, worse baseline PROMs, the use of PCOs, and greater postoperative TK and PJA. The use of UIV hooks was protective against PJF. On multivariate analysis (without postoperative measures), a higher risk of PJF was associated with greater BMI and preoperative TK and lower preoperative PJA.