Multiple Level Involvement Research Articles

Factors Affecting the Outcome of Spine Metastases: A Single-Center Evaluation in Surgically Treated Patients

BACKGROUNDThe estimation of survival is extremely important for metastatic disease in the spine. The aim of this study was to determine the factors affecting the outcome of patients with spinal metastasis, primarily the character of neurological deficit and the histopathology of the tumor. METHODA retrospective examination was made of 158 patients with spinal metastasis who were followed up in our clinic between 2010 and 2020 and were underwent surgical intervention. The patients were examined in respect of demographic characteristics, the primary tumor, comorbidities, preoperative-postoperative Visual Analogue Scale scores, preoperative-postoperative neurological examinations and neurological deficit if present and ambulation status, postoperative survival duration, tumor localization, characteristics of the surgeries, complications, the Karnofsky Performance Scale, revised Tokuhashi, and Tomita scores. RESULTSSpinal metastasis was seen more frequently in males (72,8% male, 27,8% female). Male gender, multiple level involvement, intradural localization, and Karnofsky Performance Scale <70 were seen to cause a shorter survival time. Patients with a primary focus of hematological malignancy, breast cancer, and lymphoma had a longer survival. The revised Tokuhashi, and Tomita scores were observed to be successful in the prediction of survival. A decrease in postoperative Visual Analogue Scale score had a positive effect on functional survival. The absence of preoperative neurological deficit and the patient’s ability for preoperative and postoperative ambulation affected survival positively. The overall survival period decreased in patients who were mobilized in the early postoperative period but became non-mobile in the late period, and in those who were non-mobile in both the early and late postoperative periods. CONCLUSIONThe neurological and ambulatory status, the Tomita and Tokuhashi scores, intradural localization, and gender are the factors with a significant effect on prognosis.

An unusual case of vertebral metastasis as initial presentation of follicular thyroid carcinoma complicated with misplaced pedicle screw

Vertebral metastasis as initial presentation for follicular thyroid carcinomas is rare and requires proactive management to minimize disability considering a good associated long-term survival. A review of literature in 2019 noted 27 such cases – most of the patients had solitary vertebral metastases or multiple adjacent level involvement. Surgical treatment in such cases is usually based on the extent of fractures or neural compression in the form of decompression, debulking, or total en bloc resection and biopsy. Pedicle screw placement has been studied in several large studies, and clinically relevant misplacement is rare and revision may be required. We present a case where a patient with a pathological fracture previously evaluated and operated came to us with radiculopathy caused by metastatic mass lesion and a misplaced pedicle screw.

Surgical Outcome of Anterior Cervical Discectomy and Fusion (ACDF) with Autologous Bone Graft from Iliac Bone and Miniplate Application Over It

Objectives: To know the surgical outcome of ACDF with autologous bone graft from iliac bone and miniplate application over it.Materials and Methods: This prospective study was conducted in the Department of Neurosurgery, Hayatabad Medical Complex and Lady Reading Hospital Peshawar from 1st June 2017 to 31 December 2018. Only those patients having prolapsed intervertebral cervical discs or cervical stenosis were included while those with multiple level involvement, trauma, fracture and previously operated patients for any cervical pathology were excluded. Pre-op and postoperative data were documented. For all patients, tricortical iliac bone autograft and rigid plate instrumentation was used to optimize fusion cervical collar was not used post op. Acquired data were analyzed with SPSS v20.Results: Total 83 patients fulfilled the inclusion criteria and enrolled in the study. Out of these, 48 patients were males and 35 were females. The age range was from 17 to 63 with a mean age 52 years ± 2.5.The C5 – C6 was the commonest site for fusion C6 – C7, C3 – C4 and C4 – C5 were less common. Odom’s criteria was applied to determine the outcome of the procedure. Excellent results were noted in 70 (82%). Ten (12.05%) patients had good results. Conclusion: The ACDF with the tricortical iliac bone autograft and mini plate application is the choice treatment in appropriately selected patients. It increases chances of fusion and abates the need for post op cervical collar.

Long-term outcome of treatment of vertebral body hemangiomas with direct ethanol injection and short-segment stabilization

BackgroundVertebral body hemangiomas with myelopathy are difficult to manage. ObjectiveThe objective of this study was to evaluate the role of intraoperative ethanol embolization, surgical decompression, and instrumented short-segment fusion in vertebral hemangioma (VH) with myelopathy and long-term outcome (>24 months). Clinical Materials and MethodsThis prospective study included symptomatic VH with cord compression with myelopathy. Pathologic fractures and deformity or multilevel pathologies were excluded from the study. Surgery consisted of intraoperative bilateral pedicular absolute alcohol (<1% hydrated ethyl alcohol) injection, laminectomy, and cord decompression at the level of pathology followed by a short-segment instrumented fusion using pedicle screws. ResultsThe study included 33 patients (mean 26.9±13.2, range: 10–68 years, 18 females). The clinical features of the study were myelopathy in all patients (5 paraplegic), sphincter involvement (13), and mid back or lower back pain (7). The preoperative American Spinal Injury Association (ASIA) scores were A (7), B (11), C (6), D (8), and E (1). Majority of the patients had single vertebral involvement (30) and three patients had multiple-level involvement. Six patients underwent surgery earlier (one underwent alcohol embolization). The mean surgical time was 124±39 minutes, and the average blood loss was 274±80 cc. The mean amount of absolute alcohol injected was 14.6±5.7 cc (two patients required 20 and 25 cc). Immediate embolization was achieved in all patients, allowing laminectomy and easy removal of soft-tissue hemangioma. Post surgery, one patient had transient deterioration, and the condition of the rest of the patients improved (sphincters improved in nine patients) at a follow-up ranging 28–103 months (mean 47.6±22.3). Follow-up ASIA scores were E (26), D (4), B (2), and C (1). All patients showed evidence of bone sclerosis and relief of cord compression on follow-up imaging. ConclusionsThis is the largest study in literature showing excellent improvement, low reoperation rates after ethanol embolization, and short-segment fixation.

Spinal Implants Can Be Retained in Patients with Deep Spine Infection: A Cohort Study: 深層脊椎感染的患者可以保留脊柱植入物 - 一項隊列研究

Background/PurposeIt is unclear whether implant removal is necessary when deep spine infection of spinal instrumentation occurs. This study compares mortality, relapse, and reoperation rates between such patients with and without removal of spine implants. MethodsA total of 20 patients were retrospectively reviewed. Baseline characteristics of the implant removal and nonremoval groups were compared. Outcome measures between groups were compared using multivariable logistic regression and predictors of each outcome identified. ResultsThere were no significant differences in mortality, relapse, or reoperation rates between groups. Multiple vertebral level involvement was common (85%), and the L4 (30%) and L5 (35%) levels were most commonly involved. The majority of patients had osteomyelitis/spondylodiscitis (50%) and Staphylococcus aureus infections (60%). Thoracic spine infection was associated with relapse (odds ratio = 1.26) and reoperation (odds ratio = 1.101). ConclusionImplant removal is not always necessary in cases of deep spine infection as retention of implants is not associated with higher mortality, relapse, or reoperation rates.

Level I lymph node involvement in patients with N1b papillary thyroid carcinoma: a prospective study.

Most of the studies on the incidence, pattern, and predictive factors of lymph node (LN) metastasis with papillary thyroid carcinoma (PTC) have been performed retrospectively and no common consensus has been reached regarding the predictors for the involvement of level I LNs. This study was conducted prospectively to determine the incidence and the possible predictors of level I involvement in N1b PTC patients. The study included 30 consecutive patients with N1b stage of PTC. All the patients underwent neck dissection (ND) including level I. The relation between involvement of level I LNs and various clinicopathological variables was studied. Unilateral neck dissection was performed in 24 patients and bilateral neck dissection in six patients leading to 36 NDs. Level I was excised in all patients, with five specimens (14%) positive for metastasis. Levels II, III, IV, V, VI, and VII werepositivein52.8,58.3, 58.3, 33.3, 63, and 22.2%, respectively. Level I involvement was significantly related to the number of lymph node levels affected (p=0.003) and macroscopic extranodal invasion (p=0.04). It was not related to the involvement of other individual levels, gender, age, size of the largest thyroid nodule, size of the largest LN involved, or histo-pathological variant of the tumor. This study suggests that including level I in therapeutic neck dissection for N1b PTC patients might be recommended in selected cases of multiple level involvement and macroscopic extranodal invasion requiring sacrifice of internal jugular vein, spinal accessory nerve, or sternomastoid muscle.

Investigations of Hospitalized Cases of Pyogenic Vertebral Osteomyelitis

Pyogenic vertebral osteomyelitis is d f 昀cult to diagnose and treat. The duration of antibiotic therapy, the administration of treatment, and several other factors regarding pyogenic vertebral osteomyelitis remain contro‐ versial. The aim of this investigation was to examine its diagnosis and treatment and consider possible solutions. This was a retrospective study of 11 cases of hospitalized patients with pyogenic vertebral osteomyelitis, includ‐ ing their diagnosis, treatment, and other factors. The diagnosis of vertebral osteomyelitis was con 昀rmed with the combination of imaging and biological evidence. The Erythrocyte Sedimentation Rate (ESR) level served as an index to determine the duration of therapy. The duration from symptom onset to diagnosis was 3–63 (median 10) days. Rate of positive blood cultures were obtained in 8 cases (72.7%). The most frequent comorbidity was infective endocarditis in 4 cases (36.6%). Affected vertebrae were lumber spine in 9 cases (81.8%) and multiple level involvement in 8 cases (72.7%). The mean duration of antibiotic therapy was 69.6 ± 17.9 days, with no recurrence. Patients diagnosed with pyogenic vertebral osteomyelitis require careful examination for infective endocarditis. Lumber level and multiple level involvement were more frequent than had previously been repor‐ ted. Based on our experience, C-reactive Protein (CRP) is more useful than ESR as an index to evaluate the clinical response to therapy and may help determine the duration of treatment. It is important for general physi‐ cians to monitor vertebral osteomyelitis properly and provide an appropriate diagnosis and treatment.

Paraneoplastic neurological disorders in children with benign ovarian tumors

Aim: Paraneoplastic neurological diseases (PND) are rare, but potentially treatable disorders. Paraneoplastic encephalitis is rapidly emerging as an important but likely under-recognized condition in children. The aim of this study was to assess the prevalence and spectrum of PND in children with benign ovary tumor and the long-term outcome. Patients and methods: We retrospectively reviewed the charts of all female patients below 18years of age diagnosed with a benign ovarian tumor proven by pathology between January 1993 and December 2010. All the clinical symptoms developed within 5years of tumor diagnosis and the related investigations were recorded. Results: There were total 133 children and adolescents with benign ovarian tumors, mostly mature teratoma. Six patients (4.5%) had neuropsychiatric manifestations and all but one were beyond age 10years. The most common neuropsychiatric presentations were depression or low mood (84%), headache (50%), mutism (50%), hypoventilation (50%), seizures (30%), hallucination (30%), vomiting and hypersalivation (30%). Three patients (2.2%) had serious PND including acute disseminated encephalomyelitis in 1 and anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis in 2. Although all of three improved after tumor removal, one without immunotherapy had neurological sequelae and prolonged ICU stay. Conclusion: The prevalence of PND in benign ovary tumor is not so uncommon in children. It is important to survey ovary tumors in female adolescents with subacute presentation of multiple-level involvement of neuraxis where no clear alternate diagnosis is possible. Treatment of serious PND associated with ovary tumors should include immunotherapy in addition to tumor removal.

Pattern of Nodal Metastases in Papillary Thyroid Carcinoma

Objective: The objective of this study is to determine the pattern of nodal metastases of papillary thyroid carcinoma to regional lymph in patients who have clinically positive nodes. Study design: Cross sectional study. Methods: Between January 2008 and December 2009, a total of 50 consecutive patients (15 male and 35 female) with clinical evidence of cervical lymph node metastases of papillary thyroid carcinoma was analyzed. Patients those with previous neck dissection for non thyroid malignancies and those neck node with follicular and medullary thyroid carcinoma were excluded from the study. Results: The predominant site of metastases was level III (82%), followed by level IV (62%), level II (48%), level VI (18%) and level V (16%). So, patients in the anterolateral group (level II, III and IV) were the greatest risk of metastatic disease, with level III nodes consistently the most frequently involved. No patient exhibited in level I involvement, multiple level involvement was found in 74% (37 of 50) patients. Conclusion: The high incidence of metastatic disease found in level III and IV. The level V and VI involvement were also reasonably high. Which supports the recommendation for posterolateral and anterior neck dissection for patients with papillary thyroid carcinoma with clinically positive nodes. DOI: http://dx.doi.org/10.3329/bjo.v19i1.14862 Bangladesh J Otorhinolaryngol 2013; 19(1): 46-52

Clinical results of microsurgical bilateral decompression via unilateral approach for lumbar canal stenosis with multiple-level involvement

Clinical results of microsurgical bilateral decompression via unilateral approach for lumbar canal stenosis with multiple-level involvement

Aetiology of low back pain in young athletes: role of sport type

BackgroundLow back pain (LBP) in young athletes is increasing. Understanding spinal pathology related to sports may enhance design of prevention programs.ObjectiveTo test the hypothesis that rowing athletes with LBP have...

Spondylodiscitis Associated With Multiple Level Involvement and Negative Microbiological Tests

A case report. To report an unusual case of spondylodiscitis with multiple level involvement. Spondylodiscitis, an infection of the intervertebral disc space, vertebral bodies, or the paraspinal epidural space can be a serious disease because of diagnostic delay and inadequate treatment. A previously healthy, 52-year-old man was presented to our outpatient clinic with a complaint of acute, atraumatic onset of severe back pain for more than 1 month. Initially, he was misdiagnosed at another clinic as myofascial pain and treated with nonsteroidal anti-inflammatories and physical therapy, which he did not benefit from. He never complained of fever; however, laboratory tests revealed raised erythrocyte sedimentation values, increased C-reactive protein values but normal leukocyte count. Thoracal and lumbal plain radiographs were nonspecific. Magnetic resonance imaging demonstrated increased signal intensity in vertebral bodies and intervertebral disc space through T12-L4 and in the paravertebral musculature at L2-L3 with contrast enhancement. Blood cultures and computed tomography-guided needle biopsy and cultures were negative. The patient was treated with oral amoxicillin and clavulanate and responded very well clinically; however, imaging examinations were repeated up to 6 months because of multilevel involvement. Follow-up magnetic resonance imaging findings at 3 months and 6 months showed decreased signal intensity, and luckily, there was no evidence of vertebral destruction. Diagnosis of spondylodiscitis could be challenging and commonly missed; however, it should always be included in the differential diagnoses of back pain in the middle aged and healthy population.

Anterior Spinal Fusion versus Laminoplasty for Cervical Spondylotic Myelopathy: A Retrospective Review

To compare outcomes of anterior spinal fusion (ASF) versus laminoplasty for cervical spondylotic myelopathy (CSM). Records of 26 women and 37 men aged 34 to 83 (mean, 67) years who underwent ASF or laminoplasty for CSM were reviewed. Patient demographics, duration of symptoms, pre- and post-operative Japanese Orthopaedic Association (JOA) scores, Hirabayashi recovery rate, and radiographic features (including anteroposterior canal diameter, Pavlov ratio, and number of levels compressed) were compared. The mean duration of symptoms was 9 months. The mean follow-up period was 40 months. Patients who underwent laminoplasty were older (p=0.015) and had more levels compressed (p<0.001) than those who underwent ASF. Patients with C3/4 compression were older than those without it (p=0.044). Younger patients had higher Hirabayashi recovery rate (p=0.043). The surgical decision for ASF or laminoplasty mainly depends on the number of levels compressed and patient age. Laminoplasty is usually reserved for older patients with multiple level involvement. Age is the main predictive factor for surgical outcome.

Clinicopathological features of small-sized non-small cell lung cancer with mediastinal lymph node metastasis

Introduction In clinical practice, peripheral small-sized lung cancers with positive mediastinal lymph nodes are sometimes detected. To understand the characteristics of these aggressive tumors, we reviewed the clinicopathological features of small-sized non-small cell lung cancer patients with mediastinal lymph node metastasis resected in our institution. Methods We studied 360 patients with small-sized lung lesions with a maximum diameter of 2 cm or less. The clinicopathological characteristics of each patient were reviewed and compared among the subgroups, which were stratified according to pathological nodal status. Results 21 patients (5.8%) had a positive mediastinal lymph node. Among them, 17 patients had lung lesions larger than 1.5 cm. No mediastinal nodal involvement was found in patients with squamous cell carcinomas. In contrast, mediastinal nodal involvement was significantly common in patients with poorly differentiated carcinoma ( P = 0.004) and high serum carcinoembryonic antigen levels detected during preoperative evaluation ( P = 0.006). None of the 14 patients with upper lobe tumor had a positive subcarinal lymph node. Lower lobe tumors frequently developed extensive multiple-level involvement, which included the upper mediastinum. Radiographic evaluation of pN2 patients using computed tomography revealed a total absence of ground-glass opacity, or the presence of a small area of ground-glass opacity. Conclusions Most small-sized non-small cell lung cancer cases with mediastinal lymph node metastasis were invasive adenocarcinoma with poor differentiation, which usually showed a solid shadow without ground-glass opacity on computed tomography.

Brucella spondylodiscitis with multiple-level involvement, an unusual clinical presentation

Brucella spondylodiscitis with multiple-level involvement, an unusual clinical presentation

A Case of Brucella Spondylodiscitis with Extended, Multiple-level Involvement

Brucellosis is a zoonosis that affects several organs and has a protean presentation. The authors report the case of a 61-year-old male patient with brucellar spondylodiscitis involving several vertebrae and a paravertebral abscess localized in the erector spinae muscle. Diagnosis was made by positive blood culture and MRI. No relapse was seen with a combined treatment (doxycycline/rifampin) for 3 months, followed by doxycycline alone for 6 months. Almost all radiologic findings disappeared at the end of a 1-year follow-up without any further treatment.

Spine fractures in falling accidents: analysis of multidetector CT findings.

The purpose of the present study was to assess incidence, fracture type, and location of spine fractures due to falls. All emergency room CT requests during a time period of 26 months were reviewed retrospectively. Patients who had fallen or jumped and were initially examined with multidetector CT (MDCT) were included. The MDCT studies were evaluated by two radiologists for trauma location, fracture type, and multiple level involvement. A total of 237 patients (184 males, 53 female, age range 16-86 years, mean age 42 years) met the inclusion criteria. A total of 203 vertebral fractures were seen in 127 patients. Burst fracture (n=78) was the most frequent type of trauma, usually located in the thoracolumbar junction (50%). Also, compression fracture (n=52) was most common in the thoracolumbar junction (39%). Posterior column fracture (n=52) was most frequently detected in the cervical spine (40%). Multiple-level spine fractures were seen in 41 (32%) of the injured patients, of which 12 (29%) had fractures at noncontinuous levels. With increasing height the overall incidence of fractures increased, and burst fractures and multiple level spine fractures became more frequent. Age had no effect on fracture type or location. Spine fractures due to falls are common. Burst fracture is the most common fracture type and most frequently seen in the thoracolumbar junction. Multiple-level fractures were seen in 32% of the cases, of which 29% were seen at noncontinuous levels. Serious spine fractures are seen in all falling height and age groups.

Posterior approach to the degenerative cervical spine.

Laminoplasty has been gradually accepted as a treatment for choice for cervical compression myelopathy. The historical perspective of laminoplasty is described. The aims of laminoplasty are to expand the spinal canal, to secure spinal stability, to preserve the protective function of the spine, and to preserve spinal mobility. Laminoplasty is indicated in myelopathic patients with a developmentally narrow spinal canal or multiple-level involvement combined with a relatively narrow canal. Several laminoplasty techniques and supplementary techniques are described, together with expected outcomes and complications of surgery.

Peripheral small-sized (2 cm or less) non-small cell lung cancer with mediastinal lymph node metastasis; clinicopathologic features and patterns of nodal spread.

The diagnosis of small-sized (2 cm or less) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT), whereas unexpected extensive multiple-level mediastinal involvement has been occasionally detected in this small-sized lung cancer. To establish the optimal surgical strategy, we retrospectively analyzed the clinicopathologic features, efficacy of preoperative investigations and lobe specific patterns of nodal spread in small-sized NSCLC with mediastinal involvement. Among 1,550 resected lung cancer cases between 1981 and 2000, 267 (17.2%) had peripheral small-sized NSCLC. Of these, 29 patients (10.8%) with mediastinal lymph node involvement who underwent pulmonary resection and systematic nodal dissection were reviewed. Among 29 patients, 27 patients (93.1%) were adenocarcinoma, and 51.7% (15/29) showed no lymph node enlargement on CT (cN0). Surgical pathology revealed multiple-level mediastinal involvement in 65.5% (19/29) of all patients and 60.0% (9/15) of cN0 patients. All of right upper lobe tumors (n=11) showed multiple-level involvement. Thallium-201 single photon emission computed tomography (201Tl-SPECT) was positive for increased focal uptake in the mediastinum in 72.7% (8/11) of patients. The vast majority of cases were adenocarcinoma, and two thirds of them showed multiple-level mediastinal involvement, even in cN0 patients. We thus recommend to perform systematic nodal dissection or meticulous sampling for accurate intrathoracic staging, especially for right upper lobe tumor. 201Tl-SPECT appears to be more sensitive preoperative investigation for mediastinal metastasis compared with CT scan.

Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications.

Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups. The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively. The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively. This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.