Ambulatory Outcome Research Articles

AB049. Surgery for symptomatic spinal metastases-when, what and how?

Spine is the most common site for metastases in the skeletal system. Longer lifespans of patients with common cancers are translating into increasing incidence of patients with symptomatic spinal metastases. Surgery for spinal metastases offers immediate neurological decompression with stabilization and preservation of quality-of-life parameters. The objectives of the study were to assess the effect of pre-operative neurological condition, timing, and type of surgery on postoperative neurological function and long-term outcome as well as to analyze the various sources of primary in cases of symptomatic spinal metastases and the spinal level involved in terms of postoperative neurological function and ambulation. A retrospective analysis of all operated cases of symptomatic spinal metastases at our institute over a period of 5 years was performed. Parameters such as neurological presentation, timing of surgery, source of primary, and radiological features of the metastases were assessed and compared with the type of surgery performed, post-operative neurological function, and long-term outcome. The in-house hospital information system was to collect data. A total of 94 patients were operated on for symptomatic spinal metastases, the dorsal spine was the most common location and hematological malignancies were the most common primary overall and among men whereas breast was the most common primary in females. Overall, 64.8% of the patients had neurological motor deficits of which 72% had an improvement in motor power. We found that patients with a pre-operative motor power of 3/5 or more likely to have an improvement in post-operative neurological function and ambulatory status. Surgery for symptomatic spinal metastases plays a vital role in preserving the quality of life of the patients. Patients with preoperative motor power of 3/5, spastic tone, and features of mechanical back pain alone have good ambulatory outcomes post-spine surgery.

Predictive modeling of ambulatory outcomes after spinal cord injury using machine learning.

Retrospective multi-site cohort study. To develop an accurate machine learning predictive model using predictor variables from the acute rehabilitation period to determine ambulatory status in spinal cord injury (SCI) one year post injury. Model SCI System (SCIMS) database between January 2000 and May 2019. Retrospective cohort study using data that were previously collected as part of the SCI Model System (SCIMS) database. A total of 4523 patients were analyzed comparing traditional models (van Middendorp and Hicks) compared to machine learning algorithms including Elastic Net Penalized Logistic Regression (ENPLR), Gradient Boosted Machine (GBM), and Artificial Neural Networks (ANN). Compared with GBM and ANN, ENPLR was determined to be the preferred model based on predictive accuracy metrics, calibration, and variable selection. The primary metric to judge discrimination was the area under the receiver operating characteristic curve (AUC). When compared to the van Middendorp all patients (0.916), ASIA A and D (0.951) and ASIA B and C (0.775) and Hicks all patients (0.89), ASIA A and D (0.934) and ASIA B and C (0.775), ENPLR demonstrated improved AUC for all patients (0.931), ASIA A and D (0.965) ASIA B and C (0.803). Utilizing artificial intelligence and machine learning methods are feasible for accurately classifying outcomes in SCI and may provide improved sensitivity in identifying which individuals are less likely to ambulate and may benefit from augmentative strategies, such as neuromodulation. Future directions should include the use of additional variables to further refine these models.

Prenatal predictors of ambulation without assistance by 30 months of age in children following prenatal repair of open spina bifida, a systematic review and meta‐analysis

AbstractObjectivesWe aimed to investigate prenatal predictors for ambulation without assistance in children following prenatal repair of open spina bifida (OSB).MethodsA systematic search was conducted in three databases until June 2022. We included articles reporting on prenatal repair of open spina bifida (OSB) and ambulation outcomes. The random‐effect model was used. Effect sizes are presented as odds ratio (OR), using the Mantel–Haenszel test, with 95% confidence interval (CI).ResultsFive studies encompassing 460 pregnancies that underwent prenatal repair of OSB of which a total of 234 had data on ambulation and were included. The follow‐up age for all included studies was 30 months. Two studies were open repairs, two were fetoscopic repairs, and one included both open and fetoscopic repairs. Of the 234 included population, ambulation without assistance occurred in 159/234, 68% (95% CI 58, 76), and ambulation with assistance occurred in 75/234, 32% (95% CI 23.6, 41.6). Significant prenatal preoperative predictors that are negatively associated with ambulation without assistance were lateral ventricle (LV) width ≥15 mm (OR: 0.29; 95% CI 0.12, 0.69, I2 = 0.0%; p < 0.0001), lesion level T12‐L2 (OR: 0.22; 95% CI 0.07, 0.7; I2 = 65%, p = 0.01), and severe hindbrain herniation (OR: 0.28; 95% CI 0.1, 0.77; I2 = 0.0%; p = 0.01). Factors including gestational age at surgery (p = 0.5), Myeloschisis (p = 0.4), talipes (p = 0.29), and gestational age at birth (p = 0.95) were not significantly associated with ambulatory status.ConclusionFollowing the prenatal repair of OSB, preoperative factors that are negatively associated with walking without assistance were preoperative LV width ≥15 mm, lesion level T12‐L2, and preoperative severe hindbrain herniation. These results provide pertinent counselling points for parents with pregnancies affected by OSB considering a prenatal repair.

MEDIUM- AND LONG-TERM OUTCOMES OF SURGICAL RECONSTRUCTION IN ACUTE CHARCOT NEUROARTHROPATHY

IntroductionCharcot neuroarthropathy (CN) of foot and ankle presents significant challenges to the orthopaedic foot and ankle surgeon. Current treatment focuses on conservative management during the acute CN phase with offloading followed by deformity correction during the chronic phase. However, the deformity can progress in some feet despite optimal offloading resulting ulceration, infection, and limb loss. Our aim was to assess outcomes of primary surgical management with early reconstruction.MethodsBetween December 2011 and December 2019, 25 patients underwent operative intervention at our specialist diabetic foot unit for CN with progressive deformity and or instability despite advanced offloading. All had peripheral neuropathy, and the majority due to diabetes. Twenty-six feet were operated on in total - 14 during Eichenholtz stage 1 and 12 during stage 2. Fourteen of these were performed as single stage procedures, whereas 12 as two-stage reconstructions. These included isolated hindfoot reconstructions in seven, midfoot in four and combined in 14 feet. Mean age at the time of operation was 54. Preoperative ulceration was evident in 14 patients.ResultsMean follow up was 45 months (Range 12–98). There was 100% limb salvage. One-year ambulation outcomes demonstrate FWB in bespoke footwear for 17 patients and in an ankle foot orthosis (AFO), Charcot restraint orthopaedic walker (CROW) or bivalve cast for seven. All preoperative ulceration had healed. Union was achieved in 18/21 hindfoot reconstructions and 7/18 midfoot reconstructions. There were nine episodes of return to theatre, of which five were within the first 12 months. There was one episode of new ulceration.ConclusionSurgical management of acute CN (Eichenholtz one and two) of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows good rates of bony union. It should be considered in ‘foot at risk’ presentations of acute CN foot.

Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-operative Phase

ObjectiveTo formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation. DesignRetrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques. SettingRegional hospital's ambulatory rehabilitation clinic. ParticipantsPatients with major lower limb amputation (N=329). InterventionsNot applicable. Main Outcome MeasuresThe outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP. ResultsIn a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79. ConclusionThe 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.

Surgery for Symptomatic Spinal Metastases – When, What, and How?

Abstract Background: Spine is the most common site for metastases in the skeletal system. Longer lifespans of patients with common cancers are translating into increasing incidence of patients with symptomatic spinal metastases. Surgery for spinal metastases offers immediate neurological decompression with stabilization and preservation of quality-of-life parameters. Objectives: To assess the effect of pre operative neurological condition, timing, and type of surgery on post operative neurological function and long-term outcome. To analyze the various sources of primary in cases of symptomatic spinal metastases and the spinal level involved in terms of post operative neurological function and ambulation. Material and Methods: A retrospective analysis of all operated cases of symptomatic spinal metastases at our institute over a period of 5 years was performed. Parameters such as neurological presentation, timing of surgery, source of primary, radiological features of the metastases were assessed and compared with the type of surgery performed, post operative neurological function and long-term outcome. The in house hospital information system was to collect data. Results: A total of ninety-four patients were operated for symptomatic spinal metastases, the dorsal spine was the most common location and haematological malignancies were the most common primary overall and among men whereas breast was the most common primary in females. Overall, 64.8% of the patients had neurological motor deficit of which 72% had an improvement in motor power. We found that patients with a pre operative motor power of 3/5 or more likely to have in improvement in post operative neurological function and ambulatory status. Conclusion: Surgery for symptomatic spinal metastases plays a vital role in preserving the quality of life of the patients. Patients with preoperative motor power of 3/5, spastic tone and features of mechanical back pain alone have good ambulatory outcomes post spine surgery.

Development of Machine-Learning Models to Predict Ambulation Outcomes Following Spinal Metastasis Surgery.

Retrospective cohort study. This study aimed to develop machine-learning algorithms to predict ambulation outcomes following surgery for spinal metastasis. Postoperative ambulation status following spinal metastasis surgery is currently difficult to predict. The improved ability to predict this important postoperative outcome would facilitate management decision-making and help in determining realistic treatment goals. This retrospective study included patients who underwent spinal metastasis at a university-based medical center in Thailand between January 2009 and November 2021. Collected data included preoperative parameters and ambulatory status 90 and 180 days following surgery. Thirteen machine-learning algorithms, namely, artificial neural network, logistic regression, CatBoost classifier, linear discriminant analysis, extreme gradient boosting, extra trees classifier, random forest classifier, gradient boosting classifier, light gradient boosting machine, naïve Bayes, K-neighbor classifier, Ada boost classifier, and decision tree classifier were developed to predict ambulatory status 90 and 180 days following surgery. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and F1-score. In total, 167 patients were enrolled. The number of patients classified as ambulatory 90 and 180 days following surgery was 140 (81.9%) and 137 (82.0%), respectively. The extreme gradient boosting algorithm was found to most accurately predict 180-day ambulatory outcome (AUC, 0.85; F1-score, 0.90), and the decision tree algorithm most accurately predicted 90-day ambulatory outcome (AUC, 0.94; F1-score, 0.88). Machine-learning algorithms were effective in predicting ambulatory status following surgery for spinal metastasis. Based on our data, the extreme gradient boosting and decision tree best predicted postoperative ambulatory status 180 and 90 days after spinal metastasis surgery, respectively.

The Disruption of Patient Ambulation Care Processes by COVID-19: Revealing the Value of Visitor Assistance.

To explore the impact of COVID-19 on care processes and ambulation outcomes. COVID-19 forced hospital leaders to make systems-level changes that disrupted patient ambulation. The impact of these changes on the ambulation of hospitalized patients was unknown. The Systems Engineering Initiative for Patient Safety model was used to explore ambulation from a systems perspective. A single-case study research design was used to investigate patient ambulation in a major medical center. Data from 12 interviews with interdisciplinary leaders were analyzed. Staff shortages and visitor restrictions were identified as the main work system barriers to ambulation. These barriers disrupted usual ambulation processes and supported the value of visitor assistance with ambulation. This study provides a systems-level perspective of missed ambulation during COVID-19, which revealed the value of ambulation assistance provided by visitors. Findings may be used to support the continued and increased involvement of family members and visitors in the process of ambulation.

Ultrasound changes in lower limb muscle architectural parameters and ambulatory outcomes in early stroke survivors.

Ultrasound changes in lower limb muscle architectural parameters and ambulatory outcomes in early stroke survivors.

Performance of the Dutch clinical prediction rule for the ambulation outcome after spinal cord injury in a middle-income country clinical setting: an external validation study in the Thai retrospective cohort.

To perform external geographic and domain validation of the clinical prediction rule (CPR) of the ambulation outcome of patients with traumatic spinal cord injury (SCI) originally developed by van Middendorp, et al. (2011) in Thais with traumatic and non-traumatic SCI. Retrospective cohort study. A tertiary rehabilitation facility in Chiang Mai, Thailand. A validation data set, including predictive (age and four neurological variables) and outcome (ambulation status) parameters was retrospectively collected from medical records of patients with traumatic and non-traumatic SCI admitted between December 2007 and December 2019. The performance of the original model was evaluated in both discrimination and calibration aspects, using an area under the receiver-operating characteristic curve (auROC) and calibration curves, respectively. Three hundred and thirty-three patients with SCI were included in the validation set. The prevalence of ambulators was 59% (197 of 333 participants). An auROC of 0.93 (95% CI 0.90-0.96) indicated excellent discrimination whereas the calibration curve demonstrated underestimation, especially in patients with AIS grade D. Performance of the CPR was decreased but acceptable in patients with non-traumatic SCI. Our external validation study demonstrated excellent discrimination but slightly underestimated calibration of the CPR of ambulation outcome after SCI. Regardless of the geographic and etiologic background of the population, the Dutch CPR could be applied to predict the ambulation outcome in patients with SCI.

Prognosis of Cervical Diffuse Idiopathic Skeletal Hyperostosis-Related Spine Injuries in Elderly Patients: Analyses of Both Fracture and Spinal Cord Injury Without Fracture.

Retrospective multicenter study. The purpose of this study was to compare the prognosis of elderly patients with injuries related to cervical diffuse idiopathic skeletal hyperostosis (cDISH) to matched control for each group, with and without fractures. The current multicenter study was a retrospective analysis of 140 patients aged 65years or older with cDISH-related cervical spine injuries; 106 fractures and 34 spinal cord injuries without fracture were identified. Propensity score-matched cohorts from 1363 patients without cDISH were generated and compared. Logistic regression analysis was performed to determine the risk of early mortality for patients with cDISH-related injury. Patients with cDISH-related injuries with fracture did not differ significantly in the incidence of each complication and ambulation or severity of paralysis compared to matched controls. In patients with cDISH-related injury without fracture, those who were nonambulatory at discharge comprised 55% vs 34% of controls, indicating significantly poorer ambulation in those with cDISH-related injuries (P = .023). There was no significant difference in the incidence of complications and ambulation or paralysis severity at 6months as compared with controls. Fourteen patients died within 3months. Logistic regression analysis identified complete paralysis (odds ratio [OR] 36.99) and age (OR 1.24) as significant risk factors for mortality. The current study showed no significant differences in the incidence of complications, ambulation outcomes between patients with cDISH-related injury with fracture and matched controls, and that the ambulation at discharge for patients with cDISH-related injury without fractures were significantly inferior to those of matched controls.

Acute Limb Ischemia: Patient-reported Quality of Life and Ambulation Outcomes

Acute Limb Ischemia: Patient-reported Quality of Life and Ambulation Outcomes

Comparison of Pre-existing Mood Disorders and Chronic Kidney Disease as Predictors of Ambulatory Status After Major Limb Amputation.

Objective We aim to compare the effects of pre-existing mood disorders and chronic kidney disease (CKD) on ambulation outcomes for patients who have undergone major lower extremity amputation (MLEA) while also stratifying by the presence of social factors. Methods We performed a retrospective chart review of 700 patients admitted from 2014 to 2022 who underwent MLEA. We performed Chi-square tests and binomial logistic regression with p < 0.05 as our significance level. Results Mood disorder patients have higher rates of independent ambulation if they have familial support (p = 0.022), a listed primary care provider (PCP; p = 0.013), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). Patients with a history of mood disorder have significantly decreased odds of prosthesis usage (OR: 0.58, 95% CI: 0.40-0.86) but have higher rates of prosthesis usage if they have familial support (p = 0.002), a PCP listed (p = 0.005), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). CKD patients have significantly decreased odds of eventual independent ambulation (OR: 0.69, 95% CI: 0.49-0.97) but have significantly increased rates of independent ambulation if they have familial support (p =0.041) and six-month (p < 0.001) or one-year follow-up (p < 0.001). CKD patients only have significant changes in prosthesis usage with a six-month (p < 0.001) or one-year follow-up (p < 0.001). Conclusions Pre-existing CKD and mood disorders are associated with decreased odds of independent ambulation and prosthesis usage, respectively. Social factors such as family support, a listed PCP, and timely follow-up are associated with markedly improved ambulatory outcomes for MLEA patients with mood disorders and CKD, with significantly improved prosthesis usage outcomes in only the mood disorder population.

Ambulatory Outcomes of Traumatic Cauda Equina Syndrome and Conus Medullaris Syndrome: A Systematic Review

Background: The ambulatory outcomes in traumatic conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are important yet under-described. Objective: This review aimed to determine the ambulatory outcomes of patients with traumatic CMS and CES, and to identify the clinical factors affecting these outcomes. Methods: PubMed, EMBASE, CINAHL, and Cochrane databases were searched from database inception to August 2021. The searches were limited to articles in English language, human studies, and adult populations. Abstracts, letters, commentaries, editorials, conference posters, case series, case reports, and pilot studies were excluded. Two independent reviewers screened the studies, extracted relevant data regarding the ambulatory outcomes, and evaluated the risk of bias using the Joanna Briggs Institute critical appraisal checklist. If consensus could not be reached, a third reviewer arbitrated. Results: Three articles with a total of 993 participants were analysed. The risk of bias was moderate in two studies and low in one study. The descriptions of ambulatory outcomes were heterogeneous. 111 out of 214 (52%) of the patients with traumatic CES achieved independent walking after rehabilitation. Data regarding walking ability in patients with traumatic CMS were lacking. Improvements in lower limb strength and functional mobility were similar in patients with traumatic CES and those with traumatic CMS. Early rehabilitation, less severe injuries, and lower neurological injury levels are associated with more favourable ambulatory outcomes. In view of the heterogeneity of ambulatory outcomes in the included studies, meta-analysis was not conducted. Conclusions: The ambulatory outcomes of patients with traumatic CMS and CES were heterogeneous with more data available for CES. There is no evidence to suggest that traumatic CMS survivors have worsened motor and mobility prognoses than survivors with traumatic CES.

Walking Outcome After Traumatic Paraplegic Spinal Cord Injury: The Function of Which Myotomes Makes a Difference?

Background Accurate prediction of walking function after a traumatic spinal cord injury (SCI) is crucial for an appropriate tailoring and application of therapeutical interventions. Long-term outcome of ambulation is strongly related to residual muscle function acutely after injury and its recovery potential. The identification of the underlying determinants of ambulation, however, remains a challenging task in SCI, a neurological disorder presented with heterogeneous clinical manifestations and recovery trajectories. Objectives Stratification of walking function and determination of its most relevant underlying muscle functions based on stratified homogeneous patient subgroups. Methods Data from individuals with paraplegic SCI were used to develop a prediction-based stratification model, applying unbiased recursive partitioning conditional inference tree (URP–CTREE). The primary outcome was the 6-minute walk test at 6 months after injury. Standardized neurological assessments ≤15 days after injury were chosen as predictors. Resulting subgroups were incorporated into a subsequent node-specific analysis to attribute the role of individual lower extremity myotomes for the prognosis of walking function. Results Using URP–CTREE, the study group of 361 SCI patients was divided into 8 homogeneous subgroups. The node specific analysis uncovered that proximal myotomes L2 and L3 were driving factors for the differentiation between walkers and non-walkers. Distal myotomes L4–S1 were revealed to be responsible for the prognostic distinction of indoor and outdoor walkers (with and without aids). Conclusion Stratification of a heterogeneous population with paraplegic SCI into more homogeneous subgroups, combined with the identification of underlying muscle functions prospectively determining the walking outcome, enable potential benefit for application in clinical trials and practice.

Information quality management of ambulatory outcome in patients with coronary artery disease

Highlights. Using the big data databases of provided medical services belonging to the Territorial Compulsory Medical Insurance Fund and the Unified State Healthcare Information System (USHIS), clinical and statistical analysis of ambulatory follow-up of patients with coronary artery disease was carried out, an algorithm was developed and the effectiveness of the presented information management technology was determined.Aim. To assess and justify the developed information management technology for the quality management of ambulatory follow-up of patients with coronary artery disease (CAD) based on monitoring and analyzing electronic personified data on medical services.Methods. In 2018 the Territorial Compulsory Medical Insurance Fund (TCMIF), the Medical Information and Analytical Center (MIAC) and healthcare organizations of the Orenburg Region implemented information management technology to assess the quality of ambulatory follow-up in patients with CAD, which is based on big data analysis of medical services and information integration “emergency medical services (EMS), hospital-TCMIF + MIAC-polyclinic”. To assess the effectiveness of the technology, the proportion of patients with myocardial infarction (MI), death from coronary artery disease, emergency hospitalizations and emergency calls for angina pectoris were compared. The study involved two groups of patients: 13 208 ambulatory patients with angina pectoris and 4017 patients without follow-up, according to the TCMIF reports in 2017. Out of the 13,208 patients with angina pectoris in 2019, 10,205 patients with continued follow-up presented with the same clinical endpoints. Patients with these unfavorable outcomes in proportion to the total number of patients in each group in 2017 and 2019 were compared as well.Results. The developed and implemented information management technology led to an increase in the number of ambulatory patients with angina pectoris from 63 to 69%, with MI from 78 to 87%, and a reduction of emergency calls and emergency hospitalizations of patients with angina pectoris in the region in 2017 and 2019.Conclusion. Information quality management of ambulatory follow-up of patients with coronary artery disease using electronic personalized data on medical services increases the number of ambulatory patients with angina pectoris and myocardial infarction, and decreases the number of unfavorable outcomes of patients with angina pectoris.

Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results?

Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.

CORR Insights®: Are There Racial or Socioeconomic Disparities in Ambulatory Outcome or Survival After Oncologic Spine Surgery for Metastatic Cancer? Results From a Medically Underserved Center.

CORR Insights®: Are There Racial or Socioeconomic Disparities in Ambulatory Outcome or Survival After Oncologic Spine Surgery for Metastatic Cancer? Results From a Medically Underserved Center.

Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemia

BackgroundTransmetatarsal amputation (TMA) allows for maintenance of ambulatory function for patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage for patients with chronic limb threatening ischemia (CLTI). We hypothesized that CLTI patients requiring TMA will have better healing and functional outcomes with open bypass than with endovascular revascularization. MethodsConsecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. The baseline characteristics, including WIfI (wound, ischemia, foot infection) stage, noninvasive vascular studies, healing, and ambulatory outcomes, were collected. Catheter-based angiographic images were evaluated using the GLASS (global limb anatomic staging system). The primary outcomes were TMA healing and community ambulation. The secondary outcomes were TMA that had healed at study end, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses were performed. ResultsA total of 346 TMAs had been performed in 318 patients, 209 of whom had had peripheral artery disease (PAD). The median follow-up was 2.5 years. Patients with PAD had had significantly lower rates of healing compared with those without PAD (64% vs 77%; P = .007). Revascularization was performed in 185 limbs, with 102 treated endovascularly and 83 with open surgery. The patients who had undergone endovascular surgery were significantly less likely to have had the TMA healed at any point (55% vs 76%; P = .003) and less likely to have remained healed at study end (49% vs 66%; P = .02). Patients with GLASS stage 3 anatomy were significantly more likely to have healed after open surgery (75% vs 45%; P = .003). Long-term ambulation data were available for 72% of the revascularized patients. Endovascular surgery was associated with a lower likelihood of community ambulation after TMA (34% vs 57%; P = .002). On multivariable analysis, open surgery was significantly associated with TMA healing (odds ratio, 2.8; P = .007) and ambulation (odds ratio, 2.9; P = .001). ConclusionsFor patients with CLTI and significant tissue loss requiring TMA, an initial open approach to revascularization was associated with improved healing and higher rates of ambulation compared with endovascular interventions. The metabolic requirement for healing of a TMA in patients with CLTI might be better met by open revascularization.

The Ambulatory Outcomes of Traumatic Cauda Equina Syndrome and Conus Medullaris Syndrome: a Systematic Review

<h3>Objective(s)</h3> To determine the ambulatory outcomes described in traumatic CMS (tCMS) and traumatic CES (tCES), and to identify clinical factors affecting the outcomes. <h3>Data Sources</h3> Pubmed, EMBASE, CINAHL, and Cochrane databases were searched from inception to August 2021. Searches were limited to English language, human studies, and adult populations. Abstracts, letters, commentaries, editorials, conference posters, case series, case reports, and pilot studies were excluded. Reporting followed the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. <h3>Study Selection</h3> Studies were included in this systematic review if they consisted of primary studies (prospective and retrospective cohort studies) of patients with CMS and/or CES, of which trauma was the primary cause of injury; adult aged at least 19 years; the outcomes of the studies involved walking ability or description of lower extremity motor or functional recovery as an outcome. Studies were excluded if they described nontraumatic causes; or patients with pre-existing conditions that affected walking ability. <h3>Data Extraction</h3> Two independent reviewers screened the studies, extracted relevant information on the ambulatory outcomes of tCMS and tCES, and evaluated the risk of bias of the selected studies using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists. If consensus could not be reached, a third reviewer arbitrated. <h3>Data Synthesis</h3> Three of 1152 articles (n=993) were analyzed. Descriptions of ambulatory outcomes were heterogeneous ranging from percentage of patients achieving independent walking, the Lower Extremity Motor Score (LEMS), the instrument Functional Independence Measure (FIM), to the Spinal Cord Independent Measure (SCIM). Fifty-two percent (n=111) of cases with tCES achieved independent walking after rehabilitation, but data on walking ability were lacking for the tCMS cohort. Improvements in lower limb strength and functional mobility were similar in both cohorts. <h3>Conclusions</h3> There is no evidence to suggest that tCMS survivors have a worse prognosis for their motor and mobility improvement compared with tCES. Overall, early rehabilitation, less severe injury, and lower levels of injury are associated with better ambulatory outcomes in these two cohorts. <h3>Author(s) Disclosures</h3> Nothing to disclose.