Frankel Score Research Articles

A retrospective and consecutive analysis of the epidemiology and management of spinal cavernomas over the last 20 years in a single center.

Spinal cavernous malformations (SCM) are rare lesions often presenting with acute onset of symptoms and progressive neurological deterioration due to hemorrhage into the spinal cord. With the aid of modern techniques, their surgical removal became much safer. The present study was undertaken to analyze the outcome of our series of surgically and conservatively treated patients with SCM. Over a period of 20 years, 20 surgically treated and 5 conservatively managed patients with spinal cavernous malformations were identified and enrolled into this analysis. Demographic data, clinical symptoms, localization and extension of the cavernoma, as well as pre- and postoperative neurological status were obtained. The clinical status was assessed using the Frankel score. Patients were followed up clinically and by MRI. Before surgery, 90% (18/20) of our surgical patients were classified as Frankel D (93.8%), whereas two patients (10%) were graded C. None of the patients had a worse Frankel score at the time of discharge. Eighty percent of them (16 cases) remained unchanged, and 20% (4 patients) improved during the first follow-up (mean 6.3 months, range 2-17 months). All improved patients had a superficially located SCM and were operated early (≤3 months). No worsening was observed during extended follow-up (range 9-134 months, mean 44.7 months). Five nonsurgically treated patients showed no significant clinical deterioration over a period of 6.7 years (mean, range 2.9-8 years). SCM localization and number of involved segments had no influence on outcome. Our data show that SCM can be resected with favorable neurological outcome by using intraoperative neuromonitoring. Within the follow-up period, patients treated conservatively remained in a stable neurological condition.

Influence of the Preoperative Neurological Status on Survival After the Surgical Treatment of Symptomatic Spinal Metastases With Spinal Cord Compression.

Consecutive case-series. The main purpose of this study was to analyze the relationship between the preoperative neurological status and subsequent survival of patients undergoing surgical treatment for symptomatic spinal metastases. The survival of cancer patients has increased over recent years with improvements in oncologic therapy. As many as 70% of cancer patients develop spinal metastases and ∼10% of all cancer patients are treated for metastatic spinal cord compression. We retrospectively analyzed 166 patients who underwent surgery for symptomatic spinal metastases in our department between 2005 and 2012. The evaluated factors were age, primary tumor aggressiveness (slow, moderate, rapid growing), spinal location (cervical, thoracic, lumbar, and sacral), operation type (posterior decompression, anterior or posterior instrumented procedure, and radical combined instrumented surgery), preoperative evaluation using the revised Tokuhashi scoring system (<9, 9-11, and 12-15), pre- and postoperative neurological status according to the Frankel score (A-C and D-E), and the site of the main spinal cord compression (anterior, posterior, or combined). Postoperative complication and recurrence rate were also monitored. The mean age of the patients was 62 ± 12 years. The median survival time after surgery was 16.0 months. Preoperative neurological status influenced survival time significantly; the median survival was 5.1 months in Frankel A-C and 28.2 months in Frankel D-E (P < 0.001). Improvement on the Frankel scale did not influence the survival time (P = 0.131). When the patients' age was <65 years this related to a significantly longer survival time (P = 0.046). The Tokuhashi score predicted patient's survival independently (P < 0.001). The other factors had no statistical significance. The most important factors influencing postoperative survival time of these patients with symptomatic spinal metastases was the preoperative neurological condition and the Tokuhashi scoring system, which together represents a useful tool for planning the extent of surgical treatment.

Metastatic Spinal Cord Compression from Non-Small-Cell Lung Cancer Treated with Surgery and Adjuvant Therapies: A Retrospective Analysis of Outcomes and Prognostic Factors in 116 Patients.

Metastatic spinal cord compression is a disastrous consequence of non-small-cell lung cancer (NSCLC). There have been few studies of the outcomes or prognostic factors in patients with metastatic spinal cord compression from NSCLC treated with surgery and adjuvant therapies. From 2002 to 2013, 116 patients with metastatic spinal cord compression from NSCLC treated with surgery and adjuvant therapies were enrolled in this retrospective analysis. Kaplan-Meier methods and Cox regression analysis were used to estimate overall survival and identify prognostic factors for survival. Multivariate analysis suggested that the Eastern Cooperative Oncology Group performance status (ECOG-PS), preoperative and postoperative Frankel scores, postoperative adjuvant radiation therapy, and target therapy were independent prognostic factors. Ninety patients died at a median of twelve months (range, three to forty-seven months) postoperatively, and twenty-six patients were still alive at the time of final follow-up (at a median of fifteen months [range, five to fifty-four months]). The complete disappearance of deficits in spinal cord function after surgery was the most robust predictor of survival. Adjuvant radiation therapy and target therapy were also associated with a better prognosis. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

English

This study aimed to determine if physical rehabilitation, in the form of neuromuscular electrical stimulation, hospital/home exercises, and/or underwater treadmill therapy, improved recovery times for dogs undergoing thoracolumbar hemilaminectomy and fenestration for Type I intervertebral disc disease. The initial recovery time was established as time from surgery to 3 unassisted steps to fall. A modified Frankel score for stage of intervertebral disc disease was assigned at intake into physical rehabilitation and at release. The study also examined variables including age, sex, amount of time in rehabilitation, and duration of signs before surgery. Retrospective study design was used. A total of 113 dogs undergoing hemilaminectomy with fenestration for T3-L3 Type I intervertebral disc disease was used. Dogs exhibiting signs of Type I intervertebral disc disease underwent advanced diagnostics before hemilaminectomy with fenestration was performed. In hospital, physical rehabilitation included neuromuscular electrical stimulation, range of motion and sling walking. The owners received home care instructions for exercise, handling, sling walking, elimination management, and what was not allowed from the dogs. Underwater treadmill therapy was initiated 10 to 14 days postoperatively and done on a weekly basis.&nbsp; Additional exercises were progressively added to the program for strength and balance. The average recovery time in this study was 16 days and dogs spent an average of 40 days in formal physical rehabilitation. 23 dogs improved 1 full modified Frankel score (MFS) and 89 dogs did not have a full increase of 1 MFS. More time in formal rehabilitation (P &lt; 0.001) and more underwater treadmill sessions (P &lt; 0.001) increased the dog&rsquo;s chances of improvement. Physical rehabilitation improves the recovery in a portion of patients undergoing hemilaminectomy with fenestration for Type I thoracolumbar intervertebral disc disease. &nbsp; Key words: Physical rehabilitation, neuromuscular electrical stimulation, intervertebral disc disease, underwater treadmill, modified Frankel score, nociception.&nbsp

Single posterior approach for circumferential decompression and anterior reconstruction using cervical trabecular metal mesh cage in patients with metastatic spinal tumour.

BackgroundThe goal of surgical management of metastatic spinal tumours is to remove the tumour mass, restore spinal stability and alignment, and provide a better quality of life. A single posterior transpedicular approach, with circumferential decompression, for anterior reconstruction has been advocated to reduce the risk of complication and morbidity associated with a combined anterior-posterior approach. The purpose of our study was to evaluate the clinical outcomes of patients who underwent a single posterior approach for anterior reconstruction at our institution to determine the feasibility and effectiveness of the approach, including the use of a cervical trabecular metal (TM) mesh cage as a vertebral body replacer. As a secondary aim, we evaluated the effect of accumulated experience with the surgical approach on clinical outcomes.MethodsTwenty consecutive cases of single posterior approach were identified from a retrospective review of spinal surgeries performed at our institution between January 2009 and December 2012. Information on the following clinical outcomes was retrieved from the medical charts for analysis: visual analogue pain score (VAS); neurological status, classified on the Frankel scale; vertebral body reconstruction; spinal alignment, using Cobb’s angle; operative time; volume of blood loss; complications; and the modified Brodsky criteria score, which was used to classify functional recovery as excellent, good, fair, or poor.ResultsPre- to post-surgical evaluation of outcomes demonstrated a significant decrease in pain (p < 0.001), improved spinal alignment, with a mean correction angle of 12° (range, 3°–29°), and higher Frankel score (p < 0.001). No severe complications were identified, including deep surgical infection or neurologic deterioration. Eighteen patients achieved good to excellent outcomes, based on the modified Brodsky criteria (p < 0.001), with two patients dying within 9 and 11 months of their surgery. Accumulated surgical experience reduced operative time and intraoperative blood loss (p ≤ 0.007).ConclusionsA single posterior approach provided good to excellent clinical and functional outcomes. Based on this evidence, we propose that a posterior approach provides a feasible alternative to the combined posterior-anterior approach for managing patients with metastatic spinal tumours.

Prediction of Quality of Life and Survival After Surgery for Symptomatic Spinal Metastases: A Multicenter Cohort Study to Determine Suitability for Surgical Treatment.

Surgery for symptomatic spinal metastases aims to improve quality of life, pain, function, and stability. Complications in the postoperative period are not uncommon; therefore, it is important to select appropriate patients who are likely to benefit the greatest from surgery. Previous studies have focused on predicting survival rather than quality of life after surgery. To determine preoperative patient characteristics that predict postoperative quality of life and survival in patients who undergo surgery for spinal metastases. In a prospective cohort study of 922 patients with spinal metastases who underwent surgery, we performed preoperative and postoperative assessment of EuroQol EQ-5D quality of life, visual analog score for pain, Karnofsky physical functioning score, complication rates, and survival. The primary tumor type, number of spinal metastases, and presence of visceral metastases were independent predictors of survival. Predictors of quality of life after surgery included preoperative EQ-5D (P = .002), Frankel score (P < .001), and Karnofsky Performance Status (P < .001). Data from the largest prospective surgical series of patients with symptomatic spinal metastases revealed that tumor type, the number of spinal metastases, and the presence of visceral metastases are the most useful predictors of survival and that quality of life is best predicted by preoperative Karnofsky, Frankel, and EQ-5D scores. The Karnofsky score predicts quality of life and survival and is easy to determine at the bedside, unlike the EQ-5D index. Karnofsky score, tumor type, and spinal and visceral metastases should be considered the 4 most important prognostic variables that influence patient management.

Cost of Surgery for Symptomatic Spinal Metastases in the United Kingdom

Spinal metastases represent a significant health and economic burden. The average cost of surgical management varies between institutions and countries, partially a result of differences in health care system billing. This study assessed hospital costs from a single institute in the United Kingdom National Healthcare Service and identified patient factors associated with these costs. This prospective study recruited patients with confirmed symptomatic spinal metastases who presented for surgical treatment. The primary outcome was cost of inpatient treatment collected using the Patient Level Costing and Information System; preoperative details collected included patient demographics, primary tumor type, Tomita and Tokuhashi scores, pain level, EuroQol 5 dimension score, Frankel, Karnofsky, and American Society of Anesthesiologists' physical status classification system scores, and operative details. Costs were analyzed for 74 patients. The mean cost of treatment (standard deviation, SD) per patient was £ 16,885 (£ 10,687); which was mainly comprised of operating theater (25% of the total) and ward costs (27%). Better health status at presentation significantly increased total and ward costs (Frankel score P = 0.006, and EuroQol 5 dimension index P = 0.014 respectively); male sex also increased total and ward costs (P < 0.01 and P = 0.06). Operation cost showed a trend to increased costs with less impairment on American Society of Anesthesiologists' physical status classification system scores. The cost of surgical management of spinal metastases is associated with several factors but is greater in patients presenting with better health status, probably because of their suitability for larger operations, whereas those with poor health status undergo smaller, palliative operations, resulting in shorter inpatient postoperative recovery.

Metastatic Spine Tumour Surgery: Minimally Invasive versus Open Approach

Background Minimally invasive surgery (MIS) approaches have shown encouraging results for early wound healing, reduced intraoperative blood loss, and shortened hospital stay in management of degenerative spine diseases. Such surgical strategies in metastatic spine disease (MSD) are highly desirable in reducing surgical morbidity and enabling earlier initiation of oncological treatment. However, previous studies conducted were case series; none comparing the outcomes between MIS and open approaches. We aimed to investigate and compare the outcomes of open and MIS approach in patients with symptomatic MSD who underwent posterior spinal stabilization and/or decompression. Materials and Methods We prospectively analyzed data of patients undergoing surgery for MSD at our institution. We included 22 patients who underwent posterior surgery using MIS and other 22 patients using open approach. Preoperative, intraoperative, and postoperative data were collected for direct comparison of the two approaches. Generalized linear model was exploited to estimate the effect of MIS on outcomes, adjusting potential confounders. All patients were followed-up for a minimum period of 3 months from the time of surgery until the end of study period or till their demise. Results All patients showed improvement in pain and neurological status. Within 2 weeks of the operative procedure, significant pain relief (VAS score ≤ 2) was seen in 17 patients in MIS group and 12 patients in open group. t-test revealed a significant difference between preoperative and postoperative mean VAS score in the MIS as well as the open group. All patients in the two groups showed neurological improvement in postoperative period. Full normal function (Frankel score E) was achieved in 82% of the patients in the MIS group compared with 54% in the open group postoperation. Kruskal–Wallis analysis showed a significant difference in Frankel score between preoperation and postoperation in the MIS group ( p &lt; 0.01). Independent ambulation was observed within 3 months of surgery in 88% of the patients in the MIS group as compared with 64% in the open group. This difference, however, was not significant. A significant increase in the amount of blood loss was associated with more levels of decompression and larger number of screws inserted. In multivariate analysis, the amount of blood loss was significantly lower (537 mL less) in the MIS group than the open group. A significant difference in time to start radiotherapy from index surgery was observed between the MIS and open groups. Both univariate and multivariate analyses showed that patients in the MIS group could start radiotherapy 7 days earlier than those in the open group. Operative time, duration of hospital stay, and time to initiate chemotherapy were also favorable in the MIS group, though the difference was not statistically significant. Conclusion MIS in MSD has shown promising results for patients suffering from clinically significant instability, back pain, or motor deficits. The introduction of MIS can be a game-changer in the treatment of MSD because of less perioperative morbidity and allowing earlier radiotherapy and/or chemotherapy.

Outcomes following Surgical Intervention for Impending and Gross Instability (SINS criteria) Caused by Multiple Myeloma in the Spinal Column

Introduction Multiple myeloma is the most common primary tumor of the spine. Spinal multiple myeloma is classically a radiosensitive lesion; however, clinical or radiographic signs of instability merit surgical intervention. The authors present the epidemiology, surgical indications, and outcome data of the largest single series of 31 consecutive surgically treated patients with diagnoses of multiple myeloma and plasmacytoma of the spine. Methods The Spinal Instability Neoplastic Score (SINS) was utilized to make an assessment of surgical instability as the criteria for operative intervention. Patients were analyzed using lesion location, Frankel score, adjuvant therapy, outcome, and survival. Results All patients undergoing surgical intervention had either indeterminate or gross spinal column instability according to SINS criteria. Median survival was 78.9 months. No significant difference in survival was seen for patients with higher SINS scores or for older patients (&gt; 55 years). There was a statistically significant difference in survival benefit observed in patients receiving chemotherapy and radiation versus radiation alone as an adjuvant to surgery ( p = 0.02). Conclusion The report demonstrates outcomes for patients with indeterminate stability and gross spinal instability because of multiple myeloma and plasmacytoma of the spine who underwent surgical intervention with improved neurological function following surgery and low rates of instrumentation failure.

Versatility of Percutaneous Pedicular Screw Fixation in Metastatic Spine Tumor Surgery

Background Minimally invasive surgery has been evolved to address the problems associated with metastatic spine diseases (MSD). Posterior percutaneous spinal fixation (PPSF) is one of the main modalities of minimally invasive surgery. There have been several studies which evaluated the outcomes PPSF, but none of them assessed in detail regarding the versatility of PPSF in MSD. This study was designed to evaluate feasibility and spectrum of application of PPSF in management of MSD, highlighting its clinical advantages. Methods A total of 27 consecutive patients with MSD treated with PPSF in our institution from January 2011 to June 2014 were studied. All the patients, after a multidisciplinary assessment, were considered for surgical intervention because of clinical presentation of either neural deficit, skeletal instability, or both. Some of these patients belonged to poor-prognostic category based on survival prognostic scoring systems. The patients were categorized into seven groups depending on the modality of PPSF used. The categories are as follows (1) Pure skeletal stabilization, (2) Posterior stabilization with decompression, (3) Posterior stabilization with decompression and partial corpectomy, (4) Posterior stabilization with decompression plus kypho/vertebrolplasty, (5) Long construct with 2 to 3 level skip decompression, (6) Short/long construct with iliac stabilization, (7) Short/long construct pus anterior corpectomy. PPSF groups 2, 3, and 4 were collapsed into one group and groups 5 and 6 into the other group because of the similarity of these procedures barring some minor differences in complexity between the groups. The analysis was then stratified by the four groups of PPSF modalities and therefore the different variables in each group could be explored and compared. Demographic data, operative details, and clinical outcomes were investigated for each category and compared preoperatively and postoperatively. Results The median age was 60 years (range, 49–78 years). t test revealed significant difference between preoperative and postoperative mean VAS score in all groups except group 4. Significant difference between pre- and postoperative ECOG scores were seen in group 2. None of the patients in any group showed any worsening in neurological status in postoperative period. Some patients in group 2 and 3 showed improvement in neurological status. Full normal function (Frankel score E) was achieved postoperation in 88% of patients in PPSF group 1, 89% in group 2, 71% in group 3, and 50% in group 4. The differences in these scores between pre- and postoperation, however, did not reach statistically significant level. Independent ambulation was observed within 3 months of surgery in 100% in PPSF group 1, 80% in group 2, 84% in group 3, and 50% in group 4. Pure stabilization group had the lowest amount of mean blood loss (92 mL), shortest operative time (180 minutes), ICU (1 day) and hospital stays (10 days) while long construct group was observed to have greatest amount of blood loss (355 mL), longest operative time (305 minutes), and ICU stay (2.5 days). Conclusion For patients with MSD, even with predicted poor prognosis on survival prognostic scoring systems, it is possible to improve functional outcomes and quality of life with PPSF keeping surgical morbidity to a minimum. PPSF allows addressing patients with pure spinal instability successfully with least morbidity.

Prognosis after spinal cord and cauda compression in spontaneous spinal epidural hematomas.

Spontaneous spinal epidural hemorrhage (SSEH) warrants urgent surgical treatment in most cases. Which patients will benefit most from decompression is not known and the disease's rarity hampers the collection of large data series to ascertain this. Therefore, using an individual patient data (IPD) meta-analysis, we aimed to identify predictors for outcome and to obtain knowledge on the etiology of SSEH. The IPD meta-analysis is based on raw data from case reports across all studies concerning all variables of interest. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used. This led to a total of 741 unique pure SSEH patient cases from 487 journal articles. Data were extracted using a data extraction sheet and analyzed using a multivariable logistic regression model. A preoperative Frankel score of C and higher, absence of use of anticoagulants, compression of the cauda equina only, and the extension of the hematoma over 3 or 4 vertebral segments were associated with good outcome. Operative interval was not invariably associated with outcome and hypertension was not a risk factor for developing SSEH. Outcome is mainly determined by severity of preoperative neurologic deficit and use of anticoagulants. Evidence for a venous origin of SSEH is abundant in view of the observed anatomical distribution in different age categories and the absence of hypertension as an isolated risk factor.

Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status.

Spine is the most common site for skeletal metastasis in patients with malignancy. Vertebral involvement quantification, neurological status, general health status and primary tumor histology are factors to set surgical planning and therapeutic targets. We evaluated the impact of general clinical and neurological status, histologic type and surgery in survival. The study sample consisted of consecutive patients admitted from July 2010 to January 2013 for treatment. Sixty eight patients were evaluated. 23 were female and 45 were male. Main primary neoplasic sites were: breast, prostate, lung/pleura and linfoproliferative. Thirty three out of 68 received surgical treatment, 2 received percutaneous biopsy and 33 had nonsurgical treatment. Log Rank curves revealed no statistical significant difference according to histological type, surgical approach and Frankel Score. Karnofsky Score was statistically different. Histological type and clinical status were statistically associated with life expectancy in vertebral metastatic disease.

The surgical management of metastatic spinal tumors based on an Epidural Spinal Cord Compression (ESCC) scale

Background contextThere have been no previous studies looking at the outcome of surgical decompression (+/−stabilization) for various grades of epidural spinal cord compression (ESCC) due to spinal metastases. PurposeThe aim of this study was to determine the outcome of surgical treatment in patients with ESCC using the Bilsky six-point scale. Study design/SettingThis was a retrospective cohort review of prospectively collected data. Patient sampleA consecutive series of 101 patients managed over the period of 3 years for ESCC due to spinal metastases in a tertiary spine surgery referral unit were included. MethodsData on age, gender, revised Tokuhashi score, preoperative Frankel grade, tumor histology, magnetic resonance imaging scan–based Bilsky cord compression grade, postoperative Frankel grade at last follow-up, complications, and survivorship were collected. Outcome measuresFrankel grading system for function was used to evaluate the patient's preoperative and postoperative neurologic status. Patient survival and postoperative complications were also collected. ResultsAverage patient age was 64.7 years (13–88 years): 62 males and 39 females. Mean follow-up was 7.3 months (3–23.3 months). Most primary tumors were in prostate, breast, renal, lung, and the blood dyscrasias. Within the lower grade of compression (Group 1; Bilsky Grades 0,1a, 1b, and 1c; n=40), 29 patients (72.5%) had no improvement in Frankel grade, seven patients (17.5%) improved, whereas four patients (10%) deteriorated neurologically after surgery. Within the higher compression grade (Group 2; Bilsky Grades 2 and 3; n=61), 37 patients (60%) did not experience neurologic change, 20 (33%) improved, whereas neurology worsened in four patients (7%). When compared with Group 2 patients, Group 1 patients had better preoperative Frankel scores but a greater number of patients in Group 2 improved their Frankel scores significantly postoperatively. The mean revised Tokuhashi score for Groups 1 and 2 was 10 and 9.1, respectively (p=.1). The complication rate for Groups 1 and 2 was 25% and 42.6%, respectively (p=.052). Survival analysis showed no difference between the groups (Group 1: median 376 days [12–1052]; Group 2: median 326 days [12–979]; p=.62). ConclusionsSurgery can achieve improvements in neurology even in higher grades of cord compression. There is a trend toward more complications and worse survival with spinal surgery in patients with higher grades of compression.

Improved patient selection by stratified surgical intervention: Aarhus Spinal Metastases Algorithm

Background contextChoosing the best surgical treatment for patients with spinal metastases remains a significant challenge for spine surgeons. There is currently no gold standard for surgical treatments. The Aarhus Spinal Metastases Algorithm (ASMA) was established to help surgeons choose the most appropriate surgical intervention for patients with spinal metastases. PurposeThe purpose of this study was to evaluate the clinical outcome of stratified surgical interventions based on the ASMA, which combines life expectancy and the anatomical classification of patients with spinal metastases to inform surgical decision making. Study design/SettingThis is a retrospective study based on a prospective database. Patient sampleA consecutive series of 515 spinal metastatic patients who underwent surgically treatment from December 1992 to June 2012 in Aarhus University Hospital were included prospectively and analyzed in detail retrospectively. Outcome measuresSurvival time after surgery was determined for all patients. Neurological function was assessed using the Frankel score preoperatively and postoperatively (at the time of discharge). Complete outcome data were retrieved in 97.5% of this cohort. MethodsPatients with spinal metastases were identified from an institutional database that prospectively collected data since 1992. Survival status data were obtained from a national registry. Neurological function was determined from the same institutional database or local Electronic Patient Journal system. Surgeons evaluated and classified patients into five surgical groups preoperatively by using the revised Tokuhashi score (TS) and the Tomita anatomical classification (TC). ResultsThe overall median survival time of the cohort was 6.8 (95% confidence interval: 6.1–7.9) months. The median survival times in the five surgical groups determined by the ASMA were 2.1 (TS 0–4, TC 1–7), 5.1 (TS 5–8, TC 1–7), 12.1 (TS 9–11, TC 1–7 or TS 12–15, TC 7), 26.0 (TS 12–15, TC 4–6), and 36.0 (TS 12–15, TC 1–3) months. The 30-day mortality rate was 7.5%. Postoperative neurological function was maintained or improved in 469 patients (92.3%). Overall reoperation rate was 13.5%, commonly because of postoperative hematoma and new limb weakness. ConclusionsThe ASMA recommends at least two surgical options for a particular patient by determining the preoperative life expectancy and anatomical classification of the spinal metastases. This algorithm could help spine surgeons to discriminate the risks of surgeries. The ASMA provides a tool to guild surgeons to evaluate the spinal metastases patients, select potential optimal surgery, and avoid life-threatening risks.

Stereotactic radiosurgery for spinal metastases with or without separation surgery.

In patients with significant epidural spinal cord compression, initial surgical decompression and stabilization of spinal metastases, as opposed to radical oncological resection, provides a margin around the spinal cord that facilitates subsequent treatment with high-dose adjuvant stereotactic radiosurgery (SRS). If a safe margin exists between tumor and spinal cord on initial imaging, then high-dose SRS may be used as the primary therapy, eliminating the need for surgery. Selecting the appropriate approach has shown greater efficacy of tumor control, neurological outcome, and duration of response when compared with external beam radiotherapy, regardless of tumor histology. This study evaluates the efficacy of this treatment approach in a series of 57 consecutive patients. Patients treated for spinal metastases between 2007 and 2011 using the Varian Trilogy Linear Accelerator were identified retrospectively. Each received SRS, with or without initial surgical decompression and instrumentation. Medical records were reviewed to assess neurological outcome and surgical or radiation-induced complications. Magnetic resonance images were obtained for each patient at 3-month intervals posttreatment, and radiographic response was assessed as stability/regression or progression. End points were neurological outcome and local radiographic disease control at death or latest follow-up. Fifty-seven patients with 69 lesions were treated with SRS for spinal metastases. Forty-eight cases (70%) were treated with SRS alone, and 21 (30%) were treated with surgery prior to SRS. A single fraction was delivered in 38 cases (55%), while a hypofractionated scheme was used in 31 (45%). The most common histological entities were renal cell, breast, and lung carcinomas. Radiographically, local disease was unchanged or regressed in 63 of 69 tumors (91.3%). Frankel score improved or remained stable in 68 of 69 cases (98.6%). SRS, alone or as an adjunct following surgical decompression, provides durable local radiographic disease control while preserving or improving neurological function. This less-invasive alternative to radical spinal oncological resection appears to be effective regardless of tumor histology without sacrificing durability of radiographic or clinical response.

Reoperation rates in the surgical treatment of spinal metastases

Background contextThe surgical treatment in spinal metastases has been shown to improve function and neurologic outcome. Unplanned hospital readmissions can be costly and cause unnecessary harm. PurposeOur aim was to first analyze the reoperation rate and indications for this revision surgery in spinal metastases from an academic tertiary spinal institute and, second, to make comparisons on outcome (neurology and survival) against patients who underwent single surgery only. Study design/settingThis was an ambispective review of all patients treated surgically over an 8-year period considering their neurologic and survival outcome data. Statistical analysis was performed using IBM SPSS 20. Because all scale values did not follow the normal distribution and significant outlier values existed, all descriptive statistics and comparisons were made using median values and the median test. Crosstabs and Pearson correlation were used to calculate differences between percentages and ordinal/nominal values. For two population proportions, the z test was used to calculate differences. The log-rank Mantel-Cox analysis was used to compare survival. Patient sampleDuring the 8 years' study period, there were 384 patients who underwent urgent surgery for spinal metastasis. Of these, 289 patients were included who had sufficient information available. There were 31 reoperations performed (10.7%; mean age, 60 years; 13 male, 18 female). Exclusion criteria included patients treated solely by radiotherapy, patients who had undergone surgery for spinal metastasis before the study period, and those who had other causes for neurologic dysfunction such as stroke. Outcome measuresThe outcomes considered in this study were revised Tokuhashi score, preoperative/postoperative Frankel scores, and survival. MethodsWe performed an ambispective review of all patients treated surgically from our comprehensive database during the study period (October 2004 to October 2012). We reviewed all patient records on the database, including patient demographics and reoperation rates. ResultsReoperations were performed in the same admission in the majority of patients (n=20), whereas 11 patients had their second procedure in subsequent hospitalization. The reasons for their revision surgery were as follows: surgical site infection (SSI; 13 of 31 [42%]), failure of instrumentation (9 of 31 [29%]), local recurrence (5 of 31 [16%]), hematoma evacuation (2 of 31 [6%]), and others (2 of 31 [6%]).When comparing the “single surgery” and “revision surgery” groups, we found that the median preoperative and postoperative Frankel scores were similar at Grade 4 (range, 1–5) for both groups (preoperative, p=.92; postoperative, p=.87). However, 20 patients (8%) from the single surgery group and 7 (23%) from the revision group had a worse postoperative score, and this was significantly different (p=.01). No significant difference was found (p=.66) in the revised Tokuhashi score. The median number of survival days was similar (p=.719)—single surgery group: 250 days (range, 5–2,597 days) and revision group: 215 days (range, 9–1,352 days). ConclusionThere was a modest reoperation rate (10.7%) in our patients treated surgically for spinal metastases over an 8-year period. Most of these were for SSI (42%), failure of instrumentation (26%), and local recurrence (16%). Patients with metastatic disease could benefit from revision surgery with comparable median survival rates but relatively poorer neurologic outcomes. This study may help to assist with informed decision making for this vulnerable patient group.

Outcomes following surgical intervention for impending and gross instability caused by multiple myeloma in the spinal column.

Multiple myeloma is the most common primary tumor of the spine and is the most common primary malignant tumor of bone. Although spinal myeloma is classically a radiosensitive lesion, clinical or radiographic signs of instability merit surgical intervention. The authors present the epidemiology, surgical indications, and outcome data of a series of consecutive cases involving 31 surgically treated patients with diagnoses of multiple myeloma and plasmacytoma of the spine (the largest such series reported to date). Surgical instability was the criterion for operative intervention in this patient cohort. The Spinal Instability Neoplastic Score (SINS) was used to make this assessment of instability. The cases were analyzed using location of the lesion, spinal levels involved, Frankel score, adjuvant therapy, functional outcome, and patient survival. All patients undergoing surgical intervention were determined to have indeterminate or gross spinal column instability according to SINS criteria. The median survival was 78.9 months. No significant difference in survival was seen for patients with higher SINS scores or for older patients (> 55 years). There was a statistically significant difference in survival benefit observed for patients receiving chemotherapy and radiation versus radiation alone as an adjuvant to surgery (p = 0.02). In this 10-year analysis, the authors report outcomes of surgical intervention for patients with indeterminate or gross spinal instability due to multiple myeloma and plasmacytoma of the spine with improved neurological function following surgery and low rates of instrumentation failure.

The Transmanubrial Approach for Cervicothoracic Junction Lesions : Feasibility, Limitations, and Advantages.

ObjectiveWe report on the technical feasibility and limitations of the transmanubrial approach for cervicothoracic junction (CTJ) lesions and emphasize the advantage of bisecting the upper part of the manubrium in an inverted Y-shape.MethodsThirteen patients who underwent the fourteen transmanubrial approach for various CTJ lesions were enrolled during 2005-2014. For the evaluation of the accessibility for the CTJ lesion, we analyzed the two parallel line defined as a straight line parallel to the inferior and superior plateau of the upper and lower healthy vertebrae, the angle of the two parallel lines and the distance from the sternal notch to lines at the sternum on preoperative magnetic resonance images. Surgical limitations and perspectives, as well as postoperative clinical outcomes were evaluated retrospectively.ResultsThe CTJ lesions were six metastases, three primary bone tumors, two herniated discs, and one each of a traumatic dislocation with syrinx formation and tuberculous spondylitis and ossification of the posterior longitudinal ligament. If two parallel lines pass below the sternal notch, the manubriotomy should be inevitably performed. The mean preoperative Visual analogue scale score was 8 (range, 5-10), which improved to 4 (range, 0-6) postoperatively. Seven cases showed an increase in Frankel score postoperatively.ConclusionThe spatial relationship between the sternal notch and the two parallel lines to the lesion was rational to determine the feasibility of manubriotomy. The transmanubrial approach for CTJ lesions can achieve favorable clinical outcomes by providing direct decompression of lesion and effective reconstruction.

Surgical management of intradural spinal cord tumors in children and young adults: A single-center experience with 50 patients.

Background:Intradural spinal cord tumors (IDSCTs) in children and young adults are rare diseases. This present study is aimed to demonstrate our experience with a large series of children and young adults with IDSCT.Methods:A total of 50 patients aged <20 years with IDSCT treated in our department between 1990 and 2010 were included in the study. Clinical, histological, and radiological findings, treatment strategies, and clinical outcome were retrospectively assessed. Depending on the relation to the spinal cord, IDSCT were dichotomized into intramedullary SCT (IMSCT) and extramedullary SCT (EMSCT). The functional outcome was evaluated with the Frankel score assessing the longest available follow-up period.Results:Mean age was 10.3 years (range 6 months–19 years). IDSCT surgery was performed in 44 patients (88%). A common first symptom in patients with EMSCT was neck and back pain (41%), whereas monoparesis of arms (43%) were often seen in patients with IMSCT. The main duration of the symptoms was longer in patients with IMSCT. The postoperative functional outcome was generally comparable to the preoperative functional condition, while better for EMSCT (P < 0.01). The functional outcome at last follow-up correlated significantly with the preoperative Frankel score (P < 0.002).Conclusion:Due to the mostly mild impact of the surgery on the functional outcome, the surgical treatment of IDSCT in children and young patients can be uniquely advocated.

Clinical features and prognostic factors of patients with chordoma in the spine: a retrospective analysis of 153 patients in a single center.

Chordoma in the spine is relatively rare, and minimal information has been published in the literature regarding this subject. Moreover, there are controversies over prognostic factors of this disease. A retrospective analysis of chordoma in the spine was performed by survival analysis. Local relapse-free survival (LRFS) and overall survival (OS) were analyzed from the date of surgery to the date of local recurrence and death. The LRFS and OS rates were estimated using the Kaplan-Meier method to identify potential prognostic factors. Factors with P values ≤ .1 were subjected to multivariate analysis by Cox regression analysis. P values ≤ .05 were considered statistically significant. A total of 153 patients with spinal chordoma were included in the study. The mean follow-up period was 72.0 months (range, 1-279 months). Local recurrence was detected in 51 cases after initial surgery in our center, while death occurred in 42 cases. The statistical analysis suggested that tumor location of C3-L5, dedifferentiated chordoma, preoperative Frankel scores A-C, and total spondylectomy were independent prognostic factors for LRFS. In addition, total en bloc spondylectomy and Karnofsky' performance status (KPS) ≥ 80% were favorable factors for OS. Total spondylectomy, by either en bloc or piecemeal method, could significantly reduce LRFS for spinal chordoma. Location of C3-L5 is a favorable factor for LRFS, while dedifferentiated subtype and preoperative Frankel scores A-C are adverse prognostic factors. In addition, total en bloc spondylectomy and KPS ≥ 80% significantly improve overall survival of patients with spinal chordoma.