Spinal Cord Compression In Patients Research Articles

Inpatient outcomes of metastatic epidural spinal cord compression in patients with gastric cancer compared to patients with other solid cancer.

255 Background: Metastatic epidural spinal cord compression (MESCC) is an oncologic emergency which can be associated with poor outcomes for cancer patients. Our aim was to study the differences in outcomes of MESCC in patients with gastric cancer (GC-MESCC) compared to those with other solid malignancies. Methods: Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database (2016-2020) was queried to identify all solid (breast, prostate, lung, gastrointestinal, renal and thyroid) cancer patients admitted with spinal cord compression. Multivariate logistic regression was used to evaluate differences in socio-demographics, medical comorbidities and outcomes between MESCC in gastric cancer patients and those with other solid cancers. The primary outcome included inpatient mortality, length of stay (LOS), and total hospital charges (THC). Results: 78,385 patients with the above solid cancers were admitted for spinal cord compression. Among them, 710 had gastric cancer. Patients with gastric cancer were younger (Mean age: 59.1 vs 66.3 years, p < 0.001). They had higher prevalence of anemia (56 vs 41%), protein energy malnutrition (28.9 vs 18.9%, p < 0.001), and lower prevalence of COPD (8.45 vs 18.5%, p =0.003), smoking (22.5 vs 33.6%, p =0.007) and CKD (9.4 vs 12.3%, p =0.03). On multivariate regression, those with GC-MESCC had two-fold higher odds of all-cause mortality (adjusted odds ratio (aOR): 2.0; 95% CI: 1.05-3.96, p = 0.034). On subgroup analysis, mortality was about four times higher for females with GC-MESCC relative to the other group (aOR = 3.8, 95% CI: 1.69-8.52, p = 0.001). There was a trend towards increased LOS (8.9 vs 7.8 days) and THC ($115, 805 vs $96, 074) but it was not statistically significant. Compared with the other cohort, GC-MESCC patients had higher rates of blood transfusion (16.2 vs 9%, p = 0.003). Conclusions: Metastatic epidural spinal cord compression is associated with increased odds of inpatient mortality in gastric cancer patients compared to those with other solid malignancies. Hence, these patients ought to have urgent intervention and close monitoring to prevent adverse outcomes. [Table: see text]

Quantitative evaluation of the spinal cord compression in patients with cervical spondylotic myelopathy using synthetic MRI.

Objectives: This work aimed to investigate the feasibility and diagnostic value of synthetic MRI, including T1, T2 and PD values in determining the severity of cervical spondylotic myelopathy (CSM). Methods: All subjects (51 CSM patients and 9 healthy controls) underwent synthetic MRI scan on a 3.0TGEMR scanner. The cervical canal stenosis degree of subjects was graded 0-III based on the method of a MRI grading system. Regions of interest (ROIs) were manually drawn at the maximal compression level (MCL) by covering the whole spinal cord to generate T1MCL, T2MCL, and PDMCL values in grade I-III groups. Besides, anteroposterior (AP) and transverse (Trans) diameters of the spinal cord at MCL were measured in grade II and grade III groups, and relative values were calculated as follows: rAP = APMCL/APnormal, rTrans = TransMCL/Transnormal. rMIN = rAP/rTrans. Results: T1MCL value showed a decreasing trend with severity of grades (from grade 0 to grade II, p < 0.05), while it increased dramatically at grade III. T2MCL value showed no significant difference among grade groups (from grade 0 to grade II), while it increased dramatically at grade III compared to grade II (p < 0.05). PDMCL value showed no statistical difference among all grade groups. rMIN of grade III was significantly lower than that of grade II (p < 0.05). T2MCL value was negatively correlated with rMIN, whereas positively correlated with rTrans. Conclusion: Synthetic MRI can provide not only multiple contrast images but also quantitative mapping, which is showed promisingly to be a reliable and efficient method in the quantitative diagnosis of CSM.

The Impact of Targetable Mutations on Clinical Outcomes of Metastatic Epidural Spinal Cord Compression in Patients With Non-Small-Cell Lung Cancer Treated With Hybrid Therapy (Surgery Followed by Stereotactic Body Radiation Therapy).

In treatment of metastatic epidural spinal cord compression (MESCC), hybrid therapy, consisting of separation surgery, followed by stereotactic body radiation therapy, has become the mainstay of treatment for radioresistant pathologies, such as non-small-cell lung cancer (NSCLC). To evaluate clinical outcomes of MESCC secondary to NSCLC treated with hybrid therapy and to identify clinical and molecular prognostic predictors. This is a single-center, retrospective study. Adult patients (≥18 years old) with pathologically confirmed NSCLC and spinal metastasis who were treated with hybrid therapy for high-grade MESCC or nerve root compression from 2012 to 2019 are included. Outcome variables evaluated included overall survival (OS) and progression-free survival, local tumor control in the competing risks setting, surgical and radiation complications, and clinical-genomic correlations. One hundred and three patients met inclusion criteria. The median OS for this cohort was 6.5 months, with progression of disease noted in 5 (5%) patients at the index tumor level requiring reoperation and/or reirradiation at a mean of 802 days after postoperative stereotactic body radiation therapy. The 2-year local control rate was 94.6% (95% CI: 89.8-99.3). Epidermal growth factor receptor (EGFR) treatment-naïve patients who initiated EGFR-targeted therapy after hybrid therapy had significantly longer OS (hazard ratio 0.47, 95% CI 0.23-0.95, P = .04) even after adjusting for smoking status. The presence of EGFR exon 21 mutation was predictive of improved progression-free survival. Hybrid therapy in NSCLC resulted in 95% local control at 2 years after surgery. EGFR treatment-naïve patients initiating therapy after hybrid therapy had significantly improved survival advantage. EGFR-targeted therapy initiated before hybrid therapy did not confer survival benefit.

The effects of bone targeted therapy in patients with greater than two years survival with metastatic breast cancer and bone metastasis.

e13076 Background: Administration of bone targeted therapy such as zoledronic acid (ZA) or of denosumab (D) decrease the risk of skeletal related events (SRE) such as radiation to the bone, pathological bone fractures, and spinal cord compression in patients with a diagnosis of metastatic breast cancer (MBC) and bone metastasis. As these patients continue to live longer it is unknown what are the impacts from long-term administration of ZA or D among those who live longer than 2 years. Methods: This was a retrospective analysis of patients with MBC and bone metastasis who lived for more than 2 years since diagnosis and received treatment at MD Anderson Cancer Center for MBC in addition to ZA and/or D between 2015 and 2021. Patient demographics, date of diagnosis, tumor characteristics, bone targeted agent treatment plans and SRE were extracted from the institutional database and electronic health records. We defined 3 patterns of receipt of bone targeted therapy: Pattern A: ZA every 3-4 weeks; Pattern B: D every 4-6 weeks; Pattern C; D every 4-6 weeks for a period followed by every 3 months. The association between these patterns and SRE was assessed using Fisher’s exact test. Results: We included 178 patients: Pattern A with 49 patients, Pattern B with 85 patients, and Pattern C with 44 patients. The proportion of patients who suffered a SRE in Patterns A, B, and C were 22.4% (11/49), 20% (17/85), and 21.4% (10/44). There was no statistical difference in the proportion of SRE between these three groups (p = 0.92). Conclusions: We did not observe a difference in the rate of SRE between the three different patterns of bone targeted therapy administration in patients with MBC and bone metastasis. Other treatment patterns will be considered in future analysis.[Table: see text]

Pre-emptive or reactive? PROMPT spinal screening in metastatic castration-resistant prostate cancer.

Approximately 1–15% of patients with metastatic castration-resistant prostate cancer eventually develop spinal cord compression (SCC) during their disease. 1 Tazi H Manunta A Rodriguez A Patard JJ Lobel B Guillé F Spinal cord compression in metastatic prostate cancer. Eur Urol. 2003; 44: 527-532 Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar , 2 Sutcliffe P Connock M Shyangdan D Court R Kandala NB Clarke A A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression. Health Technol Assess. 2013; 17: 1-274 Crossref Scopus (85) Google Scholar Guidelines recommend urgent investigation in case of clinical suspicion to diagnose and treat SCC with surgical decompression or radiotherapy, or both. 3 Vellayappan BA Kumar N Chang EL Sahgal A Sloan AE Lo SS Novel multidisciplinary approaches in the management of metastatic epidural spinal cord compression. Future Oncol. 2018; 14: 1665-1668 Crossref PubMed Scopus (5) Google Scholar However, a third of patients with asymptomatic metastatic castration-resistant prostate cancer have radiological signs of SCC by MRI, 4 Venkitaraman R Sohaib SA Barbachano Y et al. Detection of occult spinal cord compression with magnetic resonance imaging of the spine. Clin Oncol (R Coll Radiol). 2007; 19: 528-531 Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar which raises the question of whether screening followed by treatment of asymptomatic SCC might prevent the development of clinical symptoms of pain and debilitating neurological deficits. Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration-resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trialDespite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis. Full-Text PDF Open Access

Spinal cord compression in patients with mucopolysaccharidosis

PurposeSpinal abnormalities frequently occur in patients with mucopolysaccharidosis (MPS) types I, II, IV, and VI. The symptoms are manifold, which sometimes prolongs the diagnostic process and delays therapy. Spinal stenosis (SS) with spinal cord compression due to bone malformations and an accumulation of storage material in soft tissue are serious complications of MPS disease. Data on optimal perioperative therapeutic care of SS is limited.MethodsA retrospective chart analysis of patients with MPS and SS for the time period 01/1998 to 03/2021 was performed. Demographics, clinical data, neurological status, diagnostic evaluations (radiography, MRI, electrophysiology), and treatment modalities were documented. The extent of the SS and spinal canal diameter were analyzed. A Cox regression analysis was performed to identify prognostic factors for neurological outcomes.ResultsOut of 209 MPS patients, 15 were included in this study. The most dominant type of MPS was I (–H) (n = 7; 46.7%). Preoperative neurological deterioration was the most frequent indication for further diagnostics (n = 12; 80%). The surgical procedure of choice was dorsal instrumentation with microsurgical decompression (n = 14; 93.3%). A univariate Cox regression analysis showed MPS type I (–H) to be associated with favorable neurological outcomes.ConclusionEarly detection of spinal stenosis is highly relevant in patients with MPS. Detailed neurological assessment during follow-up is crucial for timeous detection of patients at risk. The surgical intervention of choice is dorsal instrumentation with microsurgical decompression and resection of thickened intraspinal tissue. Patients with MPS type I (–H) demonstrated the best neurological course.

Editorial Comment on the Article by Mushkin M.A. et al. “Effect of Prehospital Pause on the Outcomes of Emergency Decompression and Stabilization Procedures in Patients with Tumor and Infectious Spine Diseases”

The editorial comment evaluates the current state of issue of medical care at urgent states caused by pathological vertebral fractures and spinal cord compression in patients with spine destructive diseases. The rare occurrence of pathology and the deficiency of objective data determine the lack of consensus on the medical care for this category of patients. The article by M.A. Mushkin et al helps to understand how the prehospital pause affects the outcomes of emergency decompression and stabilization procedures in patients with tumor and infectious diseases of the spine, as well as to determine how much time the surgeon has at his disposal. The author of the comment believes that close cooperation of orthopedic surgeons, neurosurgeons, oncologists is necessary to solve this problem. Even despite the absence of oncologists in the staff of emergency hospitals, telemedicine allows to receive methodological support in a timely manner for making a correct decision for each patient. Interaction between clinicians, radiologists and pathologists is equally important. An important aspect is continuity in patient care. An urgently performed spinal cord decompression is only a stage of the complex treatment. Such patients should be provided with accurate routing depending on the diagnosis and the treatment early outcome.

Spinal cord compression is associated with brain plasticity in degenerative cervical myelopathy.

The impact of spinal cord compression severity on brain plasticity and prognostic determinates is not yet fully understood. We investigated the association between the severity of spinal cord compression in patients with degenerative cervical myelopathy, a progressive disease of the spine, and functional plasticity in the motor cortex and subcortical areas using functional magnetic resonance imaging. A 3.0 T MRI scanner was used to acquire functional images of the brain in 23 degenerative cervical myelopathy patients. Patients were instructed to perform a structured finger-tapping task to activate the motor cortex to assess the extent of cortical activation. T2-weighted images of the brain and spine were also acquired to quantify the severity of spinal cord compression. The observed blood oxygen level-dependent signal increase in the contralateral primary motor cortex was associated with spinal cord compression severity when patients tapped with their left hand (r = 0.49, P = 0.02) and right hand (r = 0.56, P = 0.005). The volume of activation in the contralateral primary motor cortex also increased with spinal cord compression severity when patients tapped with their left hand (r = 0.55, P = 0.006) and right hand (r = 0.45, P = 0.03). The subcortical areas (cerebellum, putamen, caudate and thalamus) also demonstrated a significant relationship with compression severity. It was concluded that degenerative cervical myelopathy patients with severe spinal cord compression recruit larger regions of the motor cortex to perform finger-tapping tasks, which suggests that this adaptation is a compensatory response to neurological injury and tissue damage in the spinal cord.

Management of acute spinal cord compression in multiple myeloma.

Spinal cord compression (SCC) is a devastating complication of multiple myeloma and has the potential to cause loss of neurological function. The common symptoms of SCC are back pain, motor weakness, and sensory change. Once diagnosed, the patient should be managed as soon as possible to prevent permanent loss of neurological function. Currently, there have been a number of studies describing the mechanism and management experience of SCC in patients with myeloma. The clinical features, diagnostic strategies, and the roles of different therapeutic options are herein reviewed.

Spinal Cord Compression in Patients with Acute Myeloid and Lymphoid Leukemia

Introduction Acute leukemias can be divided into acute myeloid leukemia and acute lymphoblastic leukemia. Common presentations of acute leukemia include fever, symptoms of anemia, bleeding, bone pain palpable Lymph nodes or spleen and symptoms due inflation or leukocystasis. Extramedullary mass is rare and can be of myeloid tissue and known as Chloroma or myeloid (granulocytic) sarcoma which one of the WHO classifications for acute myeloid leukemia. Common sites of occurrence are skin, sinuses, bone and other. It's rarely involve central nervous system. Spinal cord involvement usually manifest as epidural mass causing cord compression. Spinal epidural tumor with acute leukemia and myeloid sarcoma is rare and can be found in 3-9% in patients with leukemia. In this review we decide to review the cases of spinal cord compression caused by acute myeloid leukemia (including Chloroma) and acute lymphoblastic leukemia due to the significance of such presentation in addition to reports that Myeloid sarcoma of the spine has very poor prognosis Methodology: We have reviewed the literature using: PubMed, google scholar, Scopus for patient with spinal cord compression and acute leukemia. We used the search term and synonyms : : acute myeloid leukemia , acute myelocytic leukemia , acute monocytic leukemia , acute lymphoblastic leukemia , acute lymphoid leukemia, chloroma , myeloid sarcoma ,granulocytic sarcoma, spinal cord compression .We included adult patients above 18 years old only cases we exclude pediatrics cases and cases of chronic leukemia's and other myeloproliferative disorders as well as cases of central nervous system involvement other than spinal cord Results We gathered the information from 98 cases with general demographics, presentation, image modality, cytogenetics and molecular in addition to management and outcome. We have found mean age for the patients is 38 years old with male predominance with 70% of the cases. The most presenting symptom was back pain in around 75% of the cases. Neurological findings showed sensory loss and parapreresis in most of the documented cases. MRI was most performed modality of imaging 63% followed by Computed tomography(CT) 15 % and then myelogram 13 %, which is least used due to invasive nature and before the era of MRI. The most common affected site on spinal cord were thoracic followed by lumbar. Cytogenetics and molecular data was not reported in most of the cases. Patients were treated with either steroids or surgery or radiotherapy and or chemotherapy while few underwent bone marrow transplant, but the most common approach was surgery+ radiotherapy + chemotherapy combination. Steroids used in most of the cases especially in the cases of acute lymphoblastic leukemia and dexamethasone was the steroids of the choice mainly. The outcome of the patients were variable, 30 % were alive at the time of the reports 30 % died and 30 % between relapse and complete remission. Conclusions Acute leukemia can be presented as mass causing spinal cord compression which is very serious. There are is no standardized management of patients with acute leukemia who presented with spinal cord compression nether guidelines or steps to follow. Some reports speculated also specific morphology and cytogenetics association with predisposition to have Extramedullary mass, however there lack of reporting of such a valuable information. Large studies including all adjusted variables required to determine if spinal cord compression presentation can be an independent risk facto or not Effective diagnosis and prompt action should take place. Figure Disclosures No relevant conflicts of interest to declare.

T1 Mapping Quantifies Spinal Cord Compression in Patients With Various Degrees of Cervical Spinal Canal Stenosis.

Age-related degeneration of the cervical spinal column is the most common cause of spinal cord lesions. T1 mapping has been shown to indicate the grade and site of spinal cord compression in low grade spinal canal stenosis (SCS). Aim of our study was to further investigate the diagnostic potential of a novel T1 mapping method at 0.75 mm resolution and 4 s acquisition time in 31 patients with various grades of degenerative cervical SCS. T1 mapping was performed in axial sections of the stenosis as well as above and below. Included subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological, and clinical examination. We found that patients with cervical SCS showed a significant difference in T1 relaxation times within the stenosis (727 ± 66 ms, mean ± standard deviation) in comparison to non-stenotic segments above (854 ± 104 ms, p < 0.001) and below (893 ± 137 ms, p < 0.001). There was no difference in mean T1 in non-stenotic segments in patients (p = 0.232) or between segments in controls (p = 0.272). Mean difference of the T1 relaxation times was significantly higher in grade III stenosis (234 ± 45) vs. in grade II stenosis (176 ± 45, p = 0.037) vs. in grade I stenosis (90 ± 87 ms, p = 0.010). A higher difference in T1 relaxation time was associated with a central efferent conduction deficit. In conclusion, T1 mapping may be useful as a tool for SCS quantification in all grades of SCS, including high-grade stenosis with myelopathy signal in conventional T2-weighted imaging.

Degenerative Cervical Myelopathy: Pathophysiology and Current Treatment Strategies.

Chronic compression or ischemia of the spinal cord in the cervical spine causes a clinical syndrome known as cervical myelopathy. Recently, a new term “degenerative cervical myelopathy (DCM)” was introduced. DCM encompasses spondylosis, intervertebral disk herniation, facet arthrosis, ligamentous hypertrophy, calcification, and ossification. The pathophysiology of DCM includes structural and functional abnormalities of the spinal cord caused by static and dynamic factors. In nonoperative patients, cervical myelopathy has a poor prognosis. Surgical treatments, such as anterior or posterior decompression accompanying arthrodesis, arthroplasty, or laminoplasty, should be considered for patients with chronic progressive cervical myelopathy. Surgical decompression can prevent the progression of myelopathy and improve the neurologic status, functional outcomes, and quality of life, irrespective of differences in medical systems and sociocultural determinants of health. The anterior surgical approach to the cervical spine has the advantage of removing or floating the intervertebral disk, osteophytes, and ossification of the posterior longitudinal ligament that compress the spinal cord directly. The posterior surgical approach to the cervical spine is mainly used for multisegment spinal cord compression in patients with cervical lordosis. In this review article, we addressed the pathophysiology, clinical manifestations, differential diagnosis, and treatment options for DCM.

101. Prospective evaluation of degenerative cervical myelopathy in asymptomatic patients over 60 years

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is caused by narrowing of the cervical spinal canal resulting in compression of the spinal cord. The diagnosis of DCM is confirmed by history, physical exam findings, and advanced imaging showing cord compression. Radcliff et al reported the incidence of undiagnosed DCM in hip fracture patients (18%) and elective hip replacement patients (0%) based on history, modified Japanese Orthopedic Association (mJOA) score, and physical exam. Other investigators have studied the specificity and sensitivity of physical exam findings for diagnosing DCM and found it to be imperfect, with 21% of patients diagnosed with DCM lacking obvious clinical signs. PURPOSE The purpose of this study was to determine the prevalence of undiagnosed DCM in patients over 60 years by combining history, physical exam, and MRI. STUDY DESIGN/SETTING Prospective case series. PATIENT SAMPLE Patients aged 60 years or older without history or current symptoms of DCM. OUTCOME MEASURES Central canal stenosis as measured by MRI, myelopathic symptoms on neurologic exam, and patient-reported outcomes (mJOA and neck disability index [NDI]). METHODS Patients 60 years and older were prospectively enrolled from primary care practices. Patients were excluded if they had a history of debilitating neck pain, inability to have a cervical MRI, neurologic disease, cognitive impairment, or prior cervical spine surgery. A cervical MRI was performed using a 3.0 Tesla imaging system and a cervical coil. NDI and mJOA scores were collected for all patients, as well as a thorough history and physical exam. MRI results were reviewed independently by an orthopedic spine surgeon and neuroradiologist. Central cervical canal stenosis was graded 0-3, with 0 indicating no canal stenosis and 3 indicating spinal cord compression with myelomalacia. Patients were diagnosed with DCM if they had myelopathic history (mJOA RESULTS Eighty patients were included in the study: 39 Males (48.8%) and 41 Females (51.2%). The average age was 68.6 years-old (range 60–90 years). The mean NDI was 2.5%, range 0-24%. The mean mJOA score for the cohort was 17.5 (range 14-18). Two patients (3.8%) had an mJOA score of 16. Two (2.5%) patients had myelomalacia on MRI but were asymptomatic. CONCLUSIONS In our study, the prevalence of cervical spinal cord compression in patients 60 years and older with minimal neck pain was found by MRI to be 37.5%. Among these patients, one was diagnosed with DCM, while two others had myelomalacia with a normal physical exam. Our data support the work of other researchers and show that patients may have MRI findings of myelomalacia but remain asymptomatic. This study confirms a small but important prevalence of spinal stenosis and spinal cord compression in patients over 60 who have minimal or no symptoms. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

An Early Myeloma Bone Disease Model in Skeletally Mature Mice as a Platform for Biomaterial Characterization of the Extracellular Matrix.

Multiple myeloma (MM) bone disease is characterized by osteolytic bone tissue destruction resulting in bone pain, fractures, vertebral collapse, and spinal cord compression in patients. Upon initial diagnosis of MM, almost 80% of patients suffer from bone disease. Earlier diagnosis and intervention in MM bone disease would potentially improve treatment outcome and patient survival. New preclinical models are needed for developing novel diagnostic markers of bone structural changes as early as possible in the disease course. Here, we report a proof-of-concept, syngeneic, intrafemoral MOPC315.BM MM murine model in skeletally mature BALB/c mice for detection and characterization of very early changes in the extracellular matrix (ECM) of MM-injected animals. Bioluminescence imaging (BLI) in vivo confirmed myeloma engraftment in 100% of the animals with high osteoclast activity within 21 days after tumor cell inoculation. Early signs of aggressive bone turnover were observed on the outer bone surfaces by high-resolution microcomputed tomography (microCT). Synchrotron phase contrast-enhanced microcomputer tomography (PCE-CT) revealed very local microarchitecture differences highlighting numerous active sites of erosion and new bone at the micrometer scale. Correlative backscattered electron imaging (BSE) and confocal laser scanning microscopy allowed direct comparison of mineralized and nonmineralized matrix changes in the cortical bone. The osteocyte lacunar-canalicular network (OLCN) architecture was disorganized, and irregular-shaped osteocyte lacunae were observed in MM-injected bones after 21 days. Our model provides a potential platform to further evaluate pathological MM bone lesion development at the micro- and ultrastructural levels. These promising results make it possible to combine material science and pharmacological investigations that may improve early detection and treatment of MM bone disease.

Pharmacoeconomics of bortezomib - a cochin cancer research centre evaluation and review

Bortezomib also known as Velcade is indicated as a parenteral agent in the treatment of multiple myeloma. In noncomparative trials in multiple myeloma patient’s early treatment was associated with a greater rate of success. Treatment with Bortezomib-based regimens was associated with improvements in health-related quality of life. Orthopaedic surgery for spinal cord compression in patients with multiple myeloma was generally predicted to be cost saving, relative to not having surgery, over the medium to long term in modelled cost analyses from a healthcare payer perspective in the UK and US. The initial cost of surgery was high, but the difference in costs between patients undergoing or not undergoing surgery was predicted to decline over time, as savings were realised from the decrease in the number of thrombocytopaenic episodes requiring treatment in patients who underwent surgery. Available pharmacoeconomic data from several countries including the Cochin Cancer Research Centre in Kerala State, India despite inherent limitations, support the use of Bortezomib in the first line treatment of multiple myeloma.

The effect of renin-angiotensin system blockers on spinal cord dysfunction and imaging features of spinal cord compression in patients with symptomatic cervical spondylosis

BACKGROUND CONTEXTCervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately, cervical myelopathy. Studies suggest a neuroprotective effect of renin-angiotensin system (RAS) inhibitors in the brain, but limited data exist regarding their impact on the spinal cord. PURPOSETo investigate whether RAS blockers and other antihypertensive drugs are correlated with preoperative functional status and imaging markers of cord compression in patients with symptomatic cervical spondylosis. STUDY DESIGNRetrospective observational study. PATIENT SAMPLEIndividuals with symptomatic degenerative cervical stenosis who underwent surgery. OUTCOME MEASURESImaging features of spinal cord compression and functional status (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales). METHODSTwo hundred sixty-six operative patients with symptomatic degenerative cervical stenosis were included. Demographic data, comorbidities, antihypertensive medications, and functional status (including mJOA and Nurick grading scales) were collected. We evaluated canal compromise, cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared with normal cord on T2-weighted magnetic resonance imaging sequences. RESULTSOf 266 patients, 41.7% were women, 58.3% were men; median age was 57.2 years; 20.6% smoked tobacco; 24.7% had diabetes mellitus. One hundred forty-nine patients (55.8%) had hypertension, 142 (95.3%) of these were taking antihypertensive medications (37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors, and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (ie, less signal intensity change in the compressed cord area) compared with untreated patients without hypertension (p=.004). Patients with hypertension had worse preoperative mJOA and Nurick scores than those without (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), whereas hypertension remained a risk factor for worse preoperative neurological status (p<.01). CONCLUSIONSIn our study, patients with hypertension who were treated with RAS inhibitors had decreased T2-weighted signal intensity change than untreated patients without hypertension. Patients with hypertension also had worse preoperative functional status. Prospective case-control studies may deepen understanding of RAS modulators in the imaging and functional status of chronic spinal cord compression.

Zoledronic Acid Versus Denosumab for Prevention of Spinal Cord Compression in Advanced Cancers With Spine Metastasis: A Meta-Analysis of Randomized Controlled Trials.

Study Design:Meta-analysis of randomized controlled trials (RCTs).Objectives:The aim was to analyze the efficacy of zoledronic acid (ZA) versus denosumab in the prevention of spinal cord compression in patients with spine metastases from advanced cancers, by evaluating all available RCTs on this subject.Methods:A systematic search of electronic databases (PubMed and MEDLINE) was performed to identify all published RCTs comparing ZA with denosumab in prevention of spinal cord compressions in spine metastases. Risk of bias of the studies was assessed. The primary outcomes evaluated were spinal cord compression.Results:Three RCTs (5274 patients) were included. Denosumab was not significantly superior to ZA in reducing the likelihood of spinal cord compression, when all tumor types were combined (odds ratio [OR] 0.92, 95% confidence interval [CI; 0.66, 1.28], P = .66). Denosumab was not significantly favored over ZA in endodermal origin (breast and prostate; OR 0.72, 95% CI [0.43, 1.19], P = .20) and mesodermal origin tumors (solid tumors and multiple myeloma; OR 1.10, 95% CI [0.72, 1.69], P = .66).Conclusion:Denosumab does not significantly reduce the likelihood of spinal cord compressions in comparison to ZA in patients with spine metastases. When spinal cord compressions were grouped by tumor origin (endodermal or mesodermal), there remained no significant difference between denosumab and ZA. Further long-term studies are needed to determine the effectiveness of these treatment regimens.

Outcome of Surgical Treatment for Spinal Cord Compression in Patients With Hematological Malignancy.

We investigated the outcome of surgical treatment of patients with radiosensitive hematological malignancies presenting with spinal cord compression. Retrospective review of 50 patients who had treatment between 1993 and 2012. The neurological outcome was favorable in 35 patients, stable in 12, whereas 3 patients deteriorated. Decompression within 48 hours from referral was associated with a superior neurological recovery (P = .001). Complications were noted in 11 patients, and 6 of these underwent secondary surgery. Early (30-day) mortality was 8%. Radiotherapy was associated with increased incidence of complications (χ2 = 0.009). Patients who had low blood hemoglobin preoperatively as well as those who remained totally bedridden postoperatively had an inferior overall survival rate (P < .001). Patients with cord compression from hematological malignancy benefit from early surgical decompression. There is an inherent high risk for complications, which increases further if radiotherapy is given. Patients failing to ambulate after surgery have a poor prognosis.

Quantification of spinal cord compression using T1 mapping in patients with cervical spinal canal stenosis - Preliminary experience.

BackgroundDegenerative changes of the cervical spinal column are the most common cause of spinal cord lesions in the elderly. Conventional clinical, electrophysiological and radiological diagnostics of spinal cord compression are often inconsistent.Materials and methodsThe feasibility and diagnostic potential of a novel T1 mapping method at 0.5 mm resolution and 4 s acquisition time was evaluated in 14 patients with degenerative cervical spinal canal stenosis (SCS) and 6 healthy controls. T1 mapping was performed in axial sections of the stenosis as well as above and below. All subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological and clinical examinations.ResultsPatients revealed significantly decreased T1 relaxation times of the compressed spinal cord within the SCS (912 ± 53 ms, mean ± standard deviation) in comparison to unaffected segments above (1027 ± 39 ms, p < .001) and below (1056 ± 93 ms, p < .001). There was no difference in mean T1 in unaffected segments in patients (p = .712) or between segments in controls (p = .443). Moreover, T1 values were significantly lower in grade II (881 ± 46 ms, p = .005) than in grade I SCS (954 ± 29 ms). Patients with central conduction deficit tended to have lower T1 values within the SCS than patients without (909 ± 50 ms vs 968 ± 7 ms, p = .069).ConclusionRapid high-resolution T1 mapping is a robust MRI method for quantifying spinal cord compression in patients with cervical SCS. It promises additional diagnostic insights and warrants more extended patient studies.

Outcomes After Radiotherapy Alone for Metastatic Spinal Cord Compression in Patients with Oligo-metastatic Breast Cancer.

Patients with oligo-metastatic breast cancer are a unique patient subgroup with more favourable outlook than most patients with metastatic disease. Prognostic factors in these patients with metastatic spinal cord compression (MSCC) were evaluated. In 159 patients irradiated for MSCC from oligo-metastatic breast cancer, seven characteristics were retrospectively analyzed including age, interval between breast cancer diagnosis and irradiation of MSCC, time developing motor deficits, ambulatory status, involved vertebrae, performance score (ECOG-PS) and radiotherapy regimen. Improvement of motor function was significantly associated with time developing motor deficits (p=0.017), post-radiotherapy ambulatory status with pre-radiotherapy ambulation (p=0.012) and ECOG-PS 1-2 (p=0.029). Radiation doses of 39-40 Gy (equivalent doses) resulted in 1- and 2-year local control of 100% and 95%. On multivariate analyses, higher doses were associated with local control (p=0.011). Pre-radiotherapy ambulatory status (p=0.001) and ECOG-PS 1-2 (p=0.002) were associated with survival. Significant prognostic factors were identified for patients with MSCC from oligo-metastatic breast cancer. Higher radiation doses improved local control.