Spinal Instability Research Articles

Treatment Outcomes in Spinal Tumors According to Patients’ Perspectives: A Focus on Indeterminate Spinal Instability

The objective of this study was to analyze treatment approaches and outcomes according to patients’ perspectives for patients with indeterminate spinal instability caused by neoplastic lesions. Data were collected from 31 patients with a total of 147 spinal neoplastic lesions, 29 of whom had lesions classified as indeterminate. These lesions were divided into two groups: the low indeterminate group (SINS 7–9) and the high indeterminate group (SINS 10–12). Conservative treatment was the primary approach (93%), resulting in improvement in 59% of cases, stability in 22%, and asymptomatic outcomes in 19%. No significant differences in self-reported outcomes were found between surgical and non-surgical treatments (p = 0.98, p = 0.18). Surgery was reserved for patients with severe pain or impending neurological compromise. Our findings suggest that conservative management is a viable option for most patients with indeterminate spinal instability caused by neoplastic lesions, provided pain and neurological stability are adequately controlled.

Keyhole decompression surgery for holospinal epidural abscess: a novel approach for spinal stability preservation.

Spinal epidural abscesses are rare yet serious conditions, often necessitating emergency surgical intervention. Holospinal epidural abscesses (HEA) extending from the cervical to the lumbosacral spine are even rarer and present significant challenges in management. This report aims to describe a case of HEA with both ventrally-located cervical and dorsally-located thoracolumbar epidural abscesses treated with a combination of anterior keyhole decompression and posterior skip decompression surgeries. A 73-year-old woman with diabetes and hypertension presented with severe neck and back pain, fever, and a marked increase in leukocytes (29980/µL) and C-reactive protein (CRP; 24.26mg/dL) levels. Magnetic resonance imaging revealed epidural abscesses extending from the cervical to lumbar spine, confirming the diagnosis of HEA. At the cervical lesion, spinal cord was compressed by ventrally-located epidural abscess. Due to the patient's poor general condition, conservative treatment was initially pursued, followed by surgical intervention targeting the most severely compressed spinal segments. Managing ventrally-located epidural abscesses poses greater challenges. In this patient, a novel anterior keyhole decompression surgery was employed to evacuate the ventrally-located cervical epidural abscess while preserving intervertebral discs and endplates. Posterior skip decompression surgery was performed, successfully reducing thoracolumbar epidural abscesses. Subsequently, anterior keyhole decompression was performed to evacuate ventrally-located epidural abscess, preserving intervertebral discs and endplates. Postoperatively, the patient's symptoms improved, and leukocyte count and CRP gradually normalized. Follow-up imaging showed resolution of the abscesses and bone remodeling within the keyhole without evidence of spinal instability and postoperative kyphosis. Management of HEA poses significant challenges, particularly in cases with ventrally-located cervical epidural abscesses. Our case highlights the efficacy of a combined surgical approach involving anterior keyhole decompression and posterior skip decompression in achieving abscess drainage and preserving spinal stability. This novel technique offers advantages over existing methods by preserving intervertebral motion and minimizing the risk of postoperative kyphosis. Further studies are warranted to validate the long-term outcomes and generalizability of this approach.

Minimally invasive management of cervical spondylodiscitis. A multicenter experience.

The urgent etiological diagnosis represents the main management objective of cervical spondylodiscitis (CSD) to start as soon as possible antibiotic treatment to prevent neurological deterioration. The present study aimed to evaluate a multicenter experience implementing a minimally invasive surgical approach (MISA) to manage CSD such pathology vs the most complex and aggressive surgical strategies currently used.This retrospective multicenter study used a database of 70 patients from five European neurosurgical centers. Patients with primary CSD underwent MISA via a limited funnel shaped cervical microdiscectomy with 4-mm anterior and 6-mm posterior longitudinal ligaments incision, PUS drainage, and extensive washing of the interbody and epidural space without fusion. Diagnosis was confirmed by clinical, imaging, laboratory, and perioperative histopathology and bacteriology.Of the 70 patients, 41 were men (58,5%), with an average age of 47.67years. Severe neck pain affected 45 patients, while 51 had single-level cervical spondylodiscitis, 14 had double-level, and 5 had triple-level involvement. Staphylococcus aureus was identified in 49 cases. Each patient received a mean of three months of antibiotics. Inflammatory markers (C-reactive protein) were moderate for four weeks, then normalized by 8-12weeks, except in one recurrence. After an average 48-month follow-up, all patients fully recovered without neurological deficit, spinal instability, or kyphotic deformity. Radiological exams confirmed bony fusion, with no recurrences of infection. MISA treatment offers a valuable, stable, and less invasive option for treating CSD, effectively identifying causative microorganisms and decompressing the spinal cord, leading to excellent patient outcomes.

Degeneration of the nucleus pulposus affects the internal volumetric strains and failure location of adjacent human metastatic vertebral bodies.

Intervertebral disc (IVD) degeneration is suspected to affect the distribution of stress and strain near the vertebral endplates and in the underlying bone. This scenario is worsened by the presence of metastatic lesions on the vertebrae (primarily thoracic vertebrae (60-80%)) which increase the risk of fracture. As such, this study aimed to evaluate the effect of IVD degeneration on the internal volumetric strains and failure modes of human metastatic vertebral bodies. Five human thoracic spinal segments including one vertebra with lytic metastases and one radiologically healthy vertebra (control) were in-situ tested in pure compression within a mCT scanner (isotropic voxel size = 39 mm). Each specimen was tested in the elastic regime before and after inducing mock IVD degeneration (enzymatic degeneration with collagenase); and at failure after IVD degeneration. The volumetric strain field was measured using a global Digital Volume Correlation approach (BoneDVC). After IVD degeneration, larger maximum (+187%, P = 0.002, 95% CI= [-4447, -1209]) and minimum (+174%, P = 0.002, 95% CI= [1679, 4258]) principal strains were observed in both metastatic and control vertebrae, with peak differences in correspondence of the IVD anulus fibrosus. IVD degeneration caused a transversal fracture pattern in the vertebrae with failure location onset in the middle portion of the vertebral body and in the cortical shell. In conclusion, IVD degeneration was found to be a key factor in determining the failure mode, suggesting the clinical relevance of including IVD level of degeneration to assess patients' risk of spinal instability. STATEMENT OF SIGNIFICANCE: Vertebrae can be affected by pathologies, like bone metastases, while intervertebral discs tend to degenerate during life. Generally, these structures and pathologies are studied separately. In this study, we explored the effects of artificial intervertebral disc degeneration on the mineralised tissues of the vertebrae with metastases. We observed that the induced intervertebral disc degeneration changes the mechanical behaviour of the vertebral trabecular bone. We believe that the findings of this study may influence the scientific community to develop new clinical tools for the prediction of the risk of fracture in vertebrae with spinal metastases, including the degeneration of the intervertebral discs as a parameter.

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

Systematic review. In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries. Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications. Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation. In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Factors Associated With the Absence of Cervical Spine Instability in Rheumatoid Arthritis: A >10-Year Prospective Multicenter Cohort Study

Objective: To identify factors associated with the absence of cervical spine instability in patients with rheumatoid arthritis (RA).Methods: Cervical spine instability was defined as the presence of at least one of the following: atlantoaxial subluxation, vertical subluxation of the axis, or subaxial subluxation. In 2001–2002, 634 enrolled outpatients with “classical” or “definite” RA underwent a radiographic cervical spine checkup. In 2012–2013, 233 (36.8%) prospectively underwent routine clinical follow-ups with a >10-year radiographic evaluation. The prevalence and independent predictive factors for no instability were analyzed by multivariable logistic regression. Next, 85 of 292 outpatients (29.1%) without baseline cervical spine instability completed consecutive >5-year and >10-year radiographic examinations. The incidence and predictors for no new development of instability were assessed similarly.Results: Among 233 patients, those without cervical spine instability decreased from 114 (48.9%) to 47 (20.2%) during >10 years. Steinbrocker peripheral joint destruction stages I–II (odds ratio [OR], 3.797; p=0.001), no corticosteroid administration (OR, 2.700; p=0.007), and no previous joint surgery (OR, 2.480; p=0.020) were predictors for no instability. Then, 33 of 85 (38.8%) consecutively followed patients without baseline cervical spine lesions did not develop instability throughout. Steinbrocker stages I–II (OR, 5.355; p=0.005) and no corticosteroid therapy (OR, 3.868; p=0.010) were predictors for no new onset of instability. C-reactive protein (CRP) level≤1.0 mg/dL was marginal in both models (n=233 [OR, 2.013; p=0.057], n=85 [OR, 2.453; p=0.075]).Conclusion: Steinbrocker stages I–II, no corticosteroids, no previous joint surgery, and possibly CRP ≤1.0 mg/dL are factors associated with >10-year absence of cervical spine instability in RA.

Impact of the Spinal Instability Neoplastic Score on Postoperative Prognosis in Patients with Metastatic Cancer of the Cervical Spine.

Background: Although the Spinal Instability Neoplastic Score (SINS) is widely utilized to evaluate spinal instability, its prognostic value for survival in patients with cervical spinal metastases remains unclear. This study investigated the association between the SINS and survival outcomes in patients with metastatic cervical spine cancer. Methods: This retrospective cohort study included 106 patients who underwent surgery for metastatic cervical spine cancer at a single institution between 1995 and 2023. Patients were divided into two groups: high SINS (≥13) and low-to-moderate SINS (0-12). Overall survival (OS) was the primary outcome and was analyzed using Kaplan-Meier estimates and Cox regression. Secondary outcomes included changes in Eastern Cooperative Oncology Group Performance Status (ECOG-PS), operation time, estimated blood loss, and postoperative complications. Results: The median OS was significantly shorter in the high SINS group compared to the low-to-moderate SINS group (5.3 months versus 8.6 months; p = 0.023). A high SINS was independently associated with increased mortality risk (hazard ratio [HR], 1.959; 95% CI, 1.221-3.143; p = 0.005). Lung cancer (HR, 4.004; 95% CI, 1.878-8.535; p < 0.001) and rectal cancer (HR, 3.293; 95% CI, 1.126-9.632; p = 0.029) were predictive of worse survival, whereas postoperative chemotherapy (HR, 0.591; 95% CI, 0.381-0.917; p = 0.019) and radiotherapy (HR, 0.531; 95% CI, 0.340-0.827; p = 0.005) were associated with improved survival. Changes in the ECOG-PS and postoperative complication rates were not significantly different between the groups. Conclusions: A high SINS was associated with significantly shorter survival in patients with metastatic cervical spine cancer, reflecting both mechanical instability and tumor aggressiveness.

Intratumoral Flow Void Diameter as a Predictor of High Intraoperative Blood Loss in Palliative Excisional Surgery for Metastatic Spinal Tumors.

Background/Objectives: Massive intraoperative blood loss (IBL) is one of the major complications in metastatic spinal tumor surgery (MSTS), and understanding the predictors of this risk is essential. This study aimed to determine the impact of the intratumoral flow void (IFV) observed on standard magnetic resonance imaging (MRI) and its association with IBL in palliative surgery for metastatic spinal tumors. Methods: This retrospective analysis included 88 palliative excisional surgeries performed at a single hospital between 2010 and 2024. Factors such as age, sex, body mass index, tumor location, histological tumor type, spinal instability neoplastic score, revised Tokuhashi score, preoperative radiation, presence of IFV, and IFV diameter were assessed in addition to surgical details such as the number of resected and instrumented vertebrae and surgical duration. Results: Of the 88 patients, 71 (80.7%) exhibited IFV, with a mean IFV diameter of 1.8 ± 1.3 mm. The univariate analysis identified a significant association between IBL and several factors, including the presence of IFV, IFV diameter, hypervascular tumor type, number of instrumented vertebrae, and surgical duration. The multivariate analysis indicated that IFV diameter had the highest standardized coefficient among the examined variables, suggesting its strong potential as a predictor of IBL. Conclusions: This is the first study to identify the IFV diameter as a critical and independent predictor of IBL in MSTS. IFV diameter, which can be easily assessed using standard MRI, should be considered in surgical planning to effectively manage bleeding.

Measuring multifidus muscles atrophy after midline lumbar fusion with cortical bone trajectory screws due to spinal instability and spondylolisthesis: a retrospective case series.

This study aimed to assess the impact of midline lumbar fusion with cortical bone trajectory screws (MIDLF/CBT) on the multifidus muscles, focusing on the evaluation of their postoperative atrophy. MIDLF/CBT is a relatively new technique increasingly used to treat spinal instability. Despite its reduced invasiveness compared to traditional posterior lumbar interbody fusion with traditional pedicle screws (PLIF/TP), concerns remain about potential damage to the multifidus muscles that are crucial for spinal stability. Understanding the extent of muscular atrophy post-MIDLF/CBT is vital for improving surgical outcomes, and potentially patient rehabilitation strategies. This study retrospectively analysed preoperative and postoperative MRI scans of patients who underwent MIDLF/CBT for degenerative segmental spondylolisthesis. The bilateral width of the multifidus muscles at the operated segment and adjacent segments was measured using axial T2-weighted MRI scans. Statistical comparisons were made using a paired t test, with significance set at p < 0.05. The study included 16 patients with an average age of 57 ± 10 years, 10 of whom (62.5%) were women, and featured a mean follow-up period of 37 ± 25 months. Postoperative measurements showed a significant reduction in the width of the multifidus muscles at the operated segment (mean difference -3.3mm, p = 0.02) and the inferior adjacent segment (-7.4 mm, p < 0.01). A decrease in muscle width at the superior adjacent segment was also observed, although this was not statistically significant. Our study concluded that MIDLF/CBT results in significant multifidus muscle atrophy at and below the operated segment, potentially impacting postoperative rehabilitation and recovery. These findings highlight the need for further research comparing MIDLF/CBT to other spinal stabilisation techniques. Additionally, incorporating functional electromyographic assessments of paraspinal muscles could provide deeper insights into the long-term consequences of spinal surgeries and helpdevelop new approaches and strategies to mitigate paravertebral muscles atrophy, thus enhancing patient outcomes.

Does physical performance demonstrate patient-reported outcomes after lumbar spine surgery?

BackgroundDue to time and setting constraints in clinical practice, performing a comprehensive assessment with both questionnaires and physical performance tests may not be possible. This study aimed to demonstrate the relationship between physical performance and patient-reported outcomes in patients after Lumbar Spine Surgery (LSS).MethodsA cross-sectional study was conducted with 50 participants who were followed up at least six months after LSS. Participants were evaluated using the Visual Analog Scale (VAS) for activity and rest, Modified Oswestry Disability Index (mODI), Lumbar Spine Instability Questionnaire (LSIQ), One Leg Stance Test (OLST), Semi-Tandem Stance Test (STST), 4 m Gait Speed Test (4MGS), and Timed Up and Go Test (TUG).ResultsOLST was moderately correlated with the mODI (r=-0.442, p < 0.01). STST moderately correlated with mODI (r=-0.356, p < 0.05). TUG was strongly correlated with mODI (r = 0.564, p < 0.01). In addition, TUG showed a moderate correlation with a-VAS and LSIQ, respectively (r1 = 0.392, r2 = 0.475, p < 0.01). A strong correlation was found between 4MGS and mODI (r=-0.535, p < 0.01). 4MGS had a moderate correlation with LSIQ (r=-0.374, p < 0.01). A regression model summary showed that the TUG, OLST, and STST were not related to r-VAS, a-VAS, mODI, and LSIQ (p > 0.01). Higher gait speed on the 4MGS test was strongly associated with lower mODI scores (standardized ß=-0.538, p = 0.021).ConclusionLess activity pain and disability are associated with good balance and performance. 4MGS can mostly predict patient-reported function in patients after LSS.

Management of atraumatic chin-on-chest deformity in newly diagnosed multiple myeloma: illustrative case.

Patients with multiple myeloma (MM) are commonly managed by multidisciplinary oncology teams in concordance with the neurological, oncological, mechanical, and systematic decision framework. Surgery is indicated for mechanical instability and/or neurological deficits. In neurologically intact and mechanically stable patients, chemo- and radiotherapy alone are often the mainstay treatment. A 66-year-old male patient presented with a kyphotic chin-on-chest deformity due to undiagnosed spinal MM. He experienced progressive neck pain and difficulty with activities of daily living (ADLs). Imaging revealed systematic bony element destruction and burst deformities at T1-2 with cervicothoracic central canal stenosis. Due to his disease burden and neurological preservation, spinal alignment was initially achieved via halo traction and immobilization, allowing him to begin systemic therapy almost immediately after diagnosis and improving vertebral bone density and construct integrity prior to surgery. He underwent C2-T10 decompression and instrumented fusion with cement augmentation. At 12 months postoperatively, the patient reported improvement in symptomology and ADLs without radiographic evidence of hardware failure or spinal instability. Spinal MM with instability can be successfully managed with gradual deformity realignment and external orthosis before surgery in a neurologically intact patient with a significant disease burden. https://thejns.org/doi/10.3171/CASE2441.

The effect of physical activity lifestyle on in-vivo passive stiffness of the lumbar spine.

The passive stiffness of the lumbar spine has direct implications on one's risk of injury and spinal instability. Therefore, the effects that physical activity lifestyle may have on the lumbar spine's passive stiffness was assessed. Participants were classified as active (n=20) or inactive (n=21) after completing a physical activity questionnaire. Passive lumbar flexion and extension trials were completed on a custom passive jig. The participant's moment-angle curves were determined, and their lumbar spine passive stiffness was analyzed by partitioning the curve into three linear stiffness regions of increasing stiffness. Stiffness in the low stiffness zone of the moment-angle curve was significantly lower in the inactive group (p=0.014). Furthermore, time spent sitting in an office chair significantly predicted the stiffness in their low stiffness zones across all participants (p=0.011). These findings suggest that physical activity lifestyle may be a potential avenue through which one's lumbar spine passive stiffness may increase, improving spinal health and stability in the population.

Finite element analysis shows minimal stability difference between individualized mini-hemilaminectomy-corpectomy and partial lateral corpectomy in a dog model.

Use finite element analysis to evaluate the biomechanical effects of spinal decompression procedures in healthy Beagle dogs, comparing individualized mini-hemilaminectomy-corpectomy (iMHC), mini-hemilaminectomy, partial lateral corpectomy (PLC), and hemilaminectomy. A finite element model of the L1-L2 functional spinal unit was generated using CT data. For each decompression model, loads were applied in 0.2-Nm steps (maximum, 2.0 Nm) in 6 directions: flexion, extension, right and left lateral bending, and right and left axial rotation. The L1 spinous process tip displacement angle was quantified numerically. Among the 4 techniques, mini-hemilaminectomy exhibited the smallest displacement angles across all directions. Hemilaminectomy exhibited the largest displacement angles in extension, flexion, right rotation, and left rotation across all techniques. Left and right lateral bending displacement angles were marginally larger for iMHC than for hemilaminectomy at 0.4 Nm; however, at 2.0 Nm, displacement angles were similar. Mini-hemilaminectomy minimizes functional spinal unit instability to the greatest extent. Hemilaminectomy is more unstable than iMHC and PLC in flexion, extension, and rotation. Mini-hemilaminectomy-corpectomy and PLC are more unstable than hemilaminectomy in lateral bending, with iMHC being slightly more unstable than PLC or nearly equal. Mini-hemilaminectomy minimizes instability to the greatest extent in cases of ventrolateral spinal compression. In cases of ventral spinal compression, iMHC may be preferable to PLC for providing equivalent stability without impeding spinal cord visualization, but both techniques can cause instability depending on loading direction, so careful attention to postoperative instability is necessary when excessive vertebral body resection is involved.

Systematic Analysis for the Reason of Revision-Surgery After Non-Total En Bloc Spondylectomy Open Surgery Among Spinal Metastatic Tumor Cases: A Retrospective Study

ObjectivesThis study examines patients with metastatic spinal disease undergoing non-total en bloc spondylectomy, focusing on revision surgery reasons and its effectiveness in treating spinal instability, neurological issues, and pain. MethodsThis study conducted a retrospective case series in a single center and included 344 patients with metastatic spinal tumor who underwent non-total en bloc spondylectomy open surgery between 2013 and 2021 and were followed up for ＞2 years. ResultsOf 344 patients, 20 (7.1%) had revision surgery due to delayed infection (n=1), fixation loosening (n=2), and tumor recurrence (n=17). The revision group had lower rates of radiotherapy (35%) and long-segment fixation (45%) than the unrevised group (60.2%, 74%; p<0.001). Decompression surgery had the highest revision rate (15.8%), followed by vertebrectomy (8.9%), separation surgery (4.7%), and hybrid surgery (2.3%). Postoperative scores and survival rates were improved in the revision group (median survival 32 vs. 11 months; P<0.05). ConclusionsLong-segment fixation with radiotherapy may reduce revision surgery need and extend the time between surgeries. Hybrid or separation surgeries lower the likelihood of revision. Revision surgery can relieve pain and improve neurological function. Patients in the revision group have longer survival times

Effects of two posterior procedures for treatment of cervical hyperextension injury with multilevel spinal stenosis: A retrospective study

BackgroundCervical hyperextension injuries (CHI), commonly resulting in central cord syndrome and spinal instability, often affect the elderly with preexisting degenerative spinal changes, leading to a need for surgical interventions that address both the compression and stability of the cervical spine. This study compares the clinical outcomes of two posterior decompression and fixation procedures for treating cervical hyperextension injury in patients with preexisting multilevel spinal canal stenosis.MethodsPatients suffering from cervical hyperextension injury combined with multilevel spinal stenosis were divided into two groups. They received laminoplasty combined with selective unilateral pedicle screw fixation or laminectomy combined with bilateral lateral mass screw fixation. The clinical records including demographic data, operation time, length of hospital stay, estimated blood loss and surgical complications were collected, and clinical outcomes were evaluated using the American Spinal Injury Association (ASIA) impairment scale. Preoperative and postoperative cervical lordosis were measured.ResultsPostoperative AISA scores were significantly increased compared with that before surgery in both groups, there was no significant differences between groups. The intraoperative blood loss in the laminoplasty group was significantly less than that in the laminectomy group and there were no significant differences in operation time and length of hospital stay between the two groups. No significant difference was found in the incidence of overall surgical complications between the two groups. There was no significant difference in the cervical lordosis after surgery compared with that before surgery in both groups.ConclusionsFor patients suffering from cervical hyperextension injury combined with preexisting multilevel spinal stenosis, both cervical laminoplasty with selective unilateral pedicle screw fixation and laminectomy with bilateral lateral mass screw fixation could achieve satisfactory clinical outcomes.

Current knowledge of vertebral osteomyelitis: a review.

As life expectancy increases worldwide, the elderly population in every country is growing in both the size and proportion. This review aims to provide a comprehensive overview of the microbiology, clinical presentation, diagnostic strategies, and therapeutic approaches to vertebral osteomyelitis, summarizing the latest evidence to guide effective treatment. A comprehensive literature search was conducted using the Medline and Embase databases to identify relevant studies on vertebral osteomyelitis. The search included the following keywords: "vertebral osteomyelitis," "spinal infection," "discitis," "spondylitis," " spondylodiscitis," and "spinal epidural abscess." Both retrospective and prospective studies, case series, and reviews were considered. This condition is commonly caused by bacteria such as Staphylococcus aureus or gram-negative bacilli, but can also be caused by other pathogens like fungi and parasites. The onset of vertebral osteomyelitis is insidious, with low specificity in clinical manifestations, often making early diagnosis difficult. Delayed or inadequate treatment may lead to sepsis, permanent neurological damage, or even death. Treatment strategies emphasize the importance of identifying the causative pathogen to guide effective antimicrobial therapy. Current consensus does not advocate for empirical antibiotic treatment unless patients exhibit signs of neurological impairment or severe sepsis. Severe cases involving neurological paralysis, spinal instability, or sepsis may require surgical intervention. Vertebral osteomyelitis requires prompt diagnosis and treatment for a good prognosis. Delayed diagnosis and treatment can lead to permanent neurological deficits or death. Identifying the causative organism is crucial for guiding appropriate antimicrobial therapy. In addition to conservative and surgical treatments, local drug delivery systems offer new approaches to managing spinal osteomyelitis.

Normative values of non-radiological surface measurement of the lumbar lordosis curvature in the standing position and its association with age, sex, and body mass index: a cross-sectional study of 2,500 healthy individuals from Iran.

A cross-sectional study. This study aimed to define the normal values of the lumbar lordosis curve (LLC) and investigate its association with sex, age, and body mass index (BMI). The importance of the human spine's sagittal alignment, particularly in the lumbar region, has been argued from the physiological and pathophysiological points of view. The LLC size is an important predictor of lumbar pathologies. Lumbar curvature misalignment, particularly increased lumbar lordosis or hypolordosis, can, in the long term, lead to spinal instability and development of disorders such as low back pain and spondylolisthesis Therefore, knowledge about the normal LLC value and its association with age, sex, and BMI, appears crucial. The study recruited 2,497 asymptomatic volunteers (1,264 women and 1,233 men) aged 5-85 years. Participants were assigned to different groups based on their sex, age, and BMI. The LLC was measured using a Flexicurve. Normal LLC values were established for different sexes, age, and BMI groups. Overall, normal LLC ranges from 10.2° to 74.9° with a mean of 42.34°±13° (male, 38.57°±11.44°; female, 46°±13.38°). LLC was generally higher by 7.5° in women than in men. A significant three-way interaction of sex, age, and BMI with LLC was found. The association of age and BMI with LLC was also significant. Our results can be used as a reference by physicians, healthcare, etc., when the LLC values in different ages and sexes are measured noninvasively. In other words, this information can be used as reference when determining whether the obtained LLC is within the normal range.

What are the factors contributing to symptomatic local recurrence in metastatic spinal cord compression after surgery?

BackgroundRisk factors for local recurrence in patients with metastatic spinal cord compression (MSCC) has not been clearly investigated. So, the purpose of this study was to identify risk factors causing local recurrence following surgeries in patients with MSCC.MethodsWe conducted a retrospective comparative study on 304 patients who underwent surgery for MSCC between March 2014 and February 2020. Local recurrence rate (LRR) was analyzed according to demographic variables, radiological variables such as level of spinal metastasis, number of non-spinal bone metastases, degree of spinal cord compression, spinal instability, and pathological fracture, and treatment-related variables such as origin of tumor, surgical treatment methods, and pre- and post- operative radiation therapy. Univariate and multivariate logistic regression analyses were performed to reveal the risk factors for local recurrence.ResultsAmong 304 patients with MSCC, 50 patients (16.4%) experienced local recurrence after surgery. Of the surgical methods, decompression alone (26/50, 52.0%) showed higher LRR compared to decompression with fixation (9/177, 5.1%) or corpectomy (11/89, 12.4%), (P = 0.002 and P = 0.018, respectively). Patients with renal cell carcinoma revealed higher LRR compared to other types (P = 0.014). It was found that the 3 or more level of spinal metastasis (P = 0.001), the 3 or more of extraspinal bone metastases (P = 0.028), and pathologic fracture (P = 0.003) were related with higher LRR. Smoking is also an independent risk factor for local recurrence in patients who underwent fixation (P = 0.026).ConclusionsSymptomatic local recurrence may be influenced by several factors, including the extent of spinal and extraspinal bone metastasis, pathologic fractures, surgical approach, and tumor origin (RCC). These factors should be carefully considered by surgeons when evaluating the risk of symptomatic local recurrence after surgery.

CASE SERIES: CHALLENGES AND OUTCOMES OF TLIF PROCEDURES IN A PERIPHERAL HOSPITAL IN BHARATPUR, RAJASTHAN

Objective: Chronic back pain, particularly from degenerative spinal conditions, significantly impacts patient quality of life, especially in regions with limited healthcare resources, such as rural Rajasthan. Transforaminal Lumbar Interbody Fusion (TLIF) has been recognized for its efficacy in treating severe spinal degeneration and instability. This case series examines the application of TLIF in a peripheral hospital setting, assessing its challenges and outcomes in such environments. Methods: This study included three patients aged 34 to 75, who underwent TLIF at a peripheral hospital in Bharatpur, Rajasthan, from February to July 2024. Detailed preoperative and postoperative evaluations were conducted, focusing on pain levels and functional mobility. Follow-ups were performed at the first, second, and fourth weeks post-surgery to monitor recovery and assess surgical success. Results: All patients reported significant improvements in pain and mobility by the first-month follow-up. The 34 y old female experienced complete pain relief and returned to full activities by four weeks. The 75 y old female and 65 y old male also showed considerable improvements in pain and function, with no severe complications noted during or after surgery. Conclusion: TLIF can be effectively implemented in peripheral hospital settings with outcomes comparable to those in higher-resource environments. This case series demonstrates the feasibility and significant benefits of advanced spinal surgeries in resource-limited settings, highlighting the potential for expanding such sophisticated interventions to improve healthcare accessibility and patient outcomes in rural areas.

BIOM-04. SINGLE-CELL RNA SEQUENCING PROTOCOL OF THE HUMAN METASTATIC PROSTATE SPINE TUMOR MICROENVIRONMENT

Abstract INTRODUCTION 90% of spine tumor patients can develop metastases with debilitating complications, such as sensorimotor dysfunction, paralysis, and spinal instability. As spine tumor patients have limited eligibility to participate in clinical trials and have heterogenous tumor pathology, there is a distinct lack of therapeutic targets and prognostication markers of disease. Thus, there is a distinct need for molecular profiling of spine tumors. OBJECTIVE We describe an OR-to-bench-top processing of spine tumors for single-cell omic studies, with samples from a metastatic prostate cancer patient to demonstrate the ability to compare molecular markers and microenvironments of difficult-to-process spine tumors and adjacent normal tissue. METHODS Under IRB protocol #Pro00101198, patients undergoing spine surgery with the Department of Neurosurgery at Duke University were consented for tissue collection. Vertebral osseous metastases and adjacent normal tissue were confirmed histologically (H&amp;E, immunohistochemistry) and radiologically (MRI, PET, CT, and x-ray). Tissues were manually and enzymatically homogenized in serum-free media with collagenase A and DNAse I to obtain a single cell suspension. Cells were then filter sterilized, erythrolyzed, counted to determine live-death ratio, resuspended to 10-20 million cells per mL, then cryopreserved for downstream standard library preparation for single-cell sequencing using the 10X genomics platform. Downstream analysis was performed using Seurat pipeline, InferCNV analysis, and SingleR. RESULTS P404S and PSA expression confirmed tumor was prostate in origin. Radiological imaging and H&amp;E staining confirmed the presence of T7 osseous metastasis. Uniform manifold approximation and project (UMAP) plots identified 12 unique clusters of immune cell subpopulations between normal and tumorous vertebrae, with their own subsets of differentially expressed genes. CONCLUSION We have developed a protocol to generate granular single cell molecular profiling for spine tumors and metastases. Applications of this protocol can aid in identifying therapeutic targets, molecular predictors of disease, and potentiate increased eligibility of patients for clinical trials.