Spinal Interventions Research Articles

Effect of spinal anesthesia-induced deafferentation on pain processing in healthy male volunteers: A task-related fMRI study.

Spinal anesthesia causes short-term deafferentation and alters the crosstalk among brain regions involved in pain perception and pain modulation. In the current study, we examined the effect of spinal anesthesia on pain response to noxious thermal stimuli in non-deafferented skin areas using a functional magnetic resonance imaging (fMRI) paradigm. Twenty-two healthy subjects participated in the study. We performed a task-based fMRI study using a randomized crossover design. Subjects were scanned under two conditions (spinal anesthesia or control) at two-time points: before and after spinal anesthesia. Spinal anesthesia resulted in sensory loss up to dermatome Th6. Calibrated heat-pain stimuli were administered to the right forearm (C8-Th1) using a box-car design (blocks of 10s on/25s off) during MRI scanning. Pain perception was measured using a visual analogue scale (1-100) at the beginning and the end of each session. Generalized estimating equations were used to examine the effect of intervention by time by order on pain scores. Similarly, higher-level effects were tested with appropriate general linear models (accounting for within-subject variations in session and time) to examine: (1) Differences in BOLD response to pain stimulus under spinal anesthesia versus control; and (2) Effects of spinal anesthesia on pain-related modulation of the cerebral activation. Complete fMRI data was available for eighteen participants. Spinal anesthesia was associated with moderate pain score increase. Significant differences in brain response to noxious thermal stimuli were present in comparison of spinal versus control condition (post-pre). Spinal condition was associated with higher BOLD signal in the bilateral inferior parietal lobule and lower BOLD signal in bilateral postcentral and precentral gyrus. Within the angular regions, we observed a positive correlation between pain scores and BOLD signal. These observations were independent from order effect (whether the spinal anesthesia was administered in the first or the second visit). However, we did observe order effect on brain regions including medial prefrontal regions, possibly related to anticipation of the experience of spinal anesthesia. The loss of sensory and motor activity caused by spinal anesthesia has a significant impact on brain regions involved in the sensorimotor and cognitive processing of noxious heat pain stimuli. Our results indicate that the anticipation or experience of a strong somatosensory response to the spinal intervention might confound and contribute to increased sensitivity to cognitive pain processing. Future studies must account for individual differences in subjective experience of pain sensation within the experimental context.

A Survey on the Choice of Spinal Cord Stimulation Parameters and Implantable Pulse Generators and on Reasons for Explantation.

Spinal Cord Stimulation (SCS) is a vital treatment for chronic intractable pain. In the last few years, the field has undergone dramatic changes in new waveform and frequency introduction as well as device miniaturization. It is important to understand contemporary practice patterns regarding these parameters. We surveyed the active membership of Spine Intervention Society (SIS), and American Society of Regional Anesthesia (ASRA) on their practices regarding various aspects of Spinal Cord Stimulation therapy. Here we report on SCS waveform usage, battery types, and causes of explant in this cohort of providers. There was similar degree of usage of tonic, burst, and 10 kHz usage at 71.5%, 74.1% and 61.7% respectively. Dorsal root ganglion stimulation was used by 32.6% and other modes of stimulation by 13.5%. Rechargeable systems were often or always used by 67.2% whereas 10% never used a rechargeable system. Most common cause of explant was loss of effectiveness, reported by 53.7%. There has been significant adoption of new waveforms in daily practice of spinal cord stimulation therapy and there is robust mixed usage of new waveforms and frequencies. Rechargeable systems are the most commonly used but primary cell is also used in significant numbers. Loss of efficacy remains the most common cause of explant for the majority of practitioners. This survey establishes practice patterns of SCS usage regarding these important variables against which future changes can be gauged.

Safe radiological spinal intervention: A multicenter snapshot survey of musculoskeletal radiologists in the UK and India

Objectives: Research, knowledge, and technological advances have promoted minimally invasive image-guided diagnostic and therapeutic intervention. Such interventions are increasingly performed for musculoskeletal diseases by radiologists within outpatient settings. The objective of this study was to ascertain levels of safe practice among musculoskeletal radiologists in the United Kingdom and the Indian public health-care system, as defined by access to spinal surgeons and anesthetists during radiological spinal procedures. Material and Methods: An online cross-sectional survey of eight questions (multiple choice and free text) was circulated among musculoskeletal radiologists in the UK and India, to evaluate: (i) Image-guided practice among musculoskeletal radiologists. (ii) Types of interventions undertaken. (iii) Practice setting. (iv) Availability of supportive, backup access to spinal surgery services. Results: A total of 53 replies were received of which 43 (81.1%) were from musculoskeletal radiologists who perform spinal interventional procedures. Spinal biopsies and injections were the most common procedures performed by the 43 eligible radiologists (79.1% and 74.4%, respectively), with vertebroplasty and sacroplasty performed by only 16.3% and 11.6%, respectively. Less than half (46.5%) of musculoskeletal radiologists performing interventional procedures did so within a hospital setting with both a spinal surgeon and an anesthetist on site, 20.9% had an anesthetist on site but no spinal surgeon and 16.3% had neither on-site. Conclusion: Minimally invasive image-guided diagnostic and therapeutic intervention is a niche sub-specialty practiced by a few musculoskeletal radiologists. Enhanced resource allocation, skills training, and multidisciplinary service provision will ultimately minimize existing deficiencies, improving patient-related clinical outcomes, and quality of care.

Improving resident confidence with a low-cost interventional spine course

BackgroundProcedure training is highly desired by residents pursuing a career in interventional pain medicine; however, the opportunities for hands-on training may vary amongst residency programs for various reasons. ObjectiveTo evaluate the change in residents’ self-perceive competence after participation in a novel low-cost resident interventional spine course, as well as how resident experience (years of training) influences change over time. This article offers step-by-step details on how to implement a resident interventional spine course. MethodsResidents completed a pre- and post-course survey in the domains of self-perceived confidence, knowledge, and skills related to interventional spine procedures. ResultsOver five years, 19 individual residents participated in an annual elective interventional spine course (four residents chose to repeat the course during their training, one of which repeated it twice). The dimensions with highest percent improved change included the ability to perform a procedure kit set-up, followed by post-procedure complication management. Residents earlier in their training showed significantly greater improvement in rating their ability to conduct a pre-procedure chart review and addressing post-procedure complications compared to more experienced residents. In addition, resident feedback regarding the course was resoundingly positive. Of the 12 graduated residents, half applied and successfully matched into a pain medicine or sports medicine fellowship. ConclusionA low-cost interventional spine course appears to be a practical option to help improve residents’ confidence related to various aspects of interventional spine procedures.

The Effect of Classroom-Based Interventions on Sedentary Behavior and Spinal Health in Schoolchildren: Systematic Review.

Multifaceted school-based interventions involving many stakeholders show promise toward the reduction of sedentary behavior (SB) and improved musculoskeletal conditions in schoolchildren. In resource-limited contexts, where schools face multiple, complex demands, broad school-based interventions may not be possible. In these settings, less complex, resource-efficient interventions are more likely to be adopted and implemented. Interventions that are limited to classrooms and that do not require broader stakeholder participation may be more appropriate to lower-resource settings. The aim of this study was to systematically search for, identify, and summarize the literature on the effectiveness of classroom-based interventions on SB and spinal health in schoolchildren. PubMed, EBSCOhost CINAHL, Web of Science, and Scopus were searched between January 1, 2021, and April 30, 2021. We included experimental studies conducted exclusively in school classrooms that objectively measured classroom SB and spinal health. The search terms related to SB, classroom sitting, and classroom neck and back pain. Studies that reported on objectively measured classroom physical activity and instrumented observation of healthy spinal behavior were included in the review. The included studies were critically appraised using the McMaster critical review form for quantitative studies. The study findings were summarized in tables, and a meta-analysis of homogeneous review outcome data was conducted. Overall, 12 experimental studies from high-income countries were included: 9 (75%) studies focused on SB, and 3 (25%) focused on spinal health. Of the 9 SB studies, 8 (89%) reported decreases in classroom sitting time. The pooled medium-term effects of a subset of SB interventions showed statistically significant decreases in sitting time (P=.03), whereas short-term effects and long-term effects were not significantly reduced (P=.13 and P=.23, respectively). A meta-analysis of spinal health studies demonstrated statistically significant improvements in spinal behavior during functional tasks (P=.005). Classroom-based interventions aimed at reducing SB and improving spinal health may be effective without placing an additional burden on teachers and parents. SB interventions must include strategies to overcome teachers' and learners' hedonic motivation to sit during class time. Standardized outcomes for school-based SB are encouraged so that findings from various settings may be pooled to determine the overall effect across studies. The use of standardized functional outcomes in spinal health studies will aid in determining the effectiveness of spinal health interventions across studies. PROSPERO International Prospective Register of Systematic Reviews CRD42020176080; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020176080.

Absence of Neuroplastic Changes in the Bilateral H-Reflex Amplitude following Spinal Manipulation with Activator IV.

Background and Objectives: Chiropractic spinal manipulation is an alternative medical procedure for treating various spinal dysfunctions. Great interest exists in investigating its neuroplastic effects on the central nervous system. Previous studies have found contradictory results in relation to the neuroplastic changes in the H-reflex amplitude as a response to manual spinal manipulation. The discrepancies could be partly due to differences in the unilateral nature of these recordings and/or the variable force exerted in manual techniques applied by distinct chiropractors. Concerning the latter point, the variability in the performance of manual interventions may bias the determination of the significance of changes in H-reflex responses derived from spinal manipulation. To investigate such responses, a chiropractic device can be used to provide more precise and reproducible results. The current contribution aimed to examine whether spinal manipulation with an Activator IV instrument generates neuroplastic effects on the bilateral H-reflex amplitude in dancers and non-dancers. Materials and Methods: A radiograph verified spinal dysfunction in both groups of participants. Since there were significant differences between groups in the mean Hmax values of the H-reflex amplitude before spinal intervention, an assessment was made of the possible dependence of the effects of spinal manipulation with Activator IV on the basal conditions. Results: Ten sessions of spinal manipulation with Activator IV did not cause statistically significant changes in the bilateral H-reflex amplitude (measured as the Hmax/Mmax ratio) in either group. Furthermore, no significant difference was detected in the effects of spinal manipulation between groups, despite their distinct basal H-reflex amplitude. Conclusions: Regarding the therapeutic benefits of a chiropractic adjustment, herein carried out with Activator IV, the present findings suggest that the mechanism of action is not on the monosynaptic H-reflex pathway. Further research is needed to understand the mechanisms involved.

The interrater reliability of Modic changes among a potential basivertebral nerve ablation population: Why AC1 may be preferred to kappa.

Interrater reliability of Modic changes is subject to variables which affect consistency in reporting. Given the importance of Modic change identification for basivertebral nerve ablation (BVNA) candidacy, interrater reliability for this specific cohort has not yet been reported. Twenty lumbar magnetic resonance images of potential basivertebral nerve candidates were independently reviewed by two neuroradiologists and two interventional spine physiatrists for the presence and characterization of Modic changes. The kappa value of their agreement on the presence of Modic changes was 0.52 (95% confidence interval [CI] 0.37-0.67), whereas agreement on the type of Modic change was 0.51 (95% CI 0.37-0.65). Using an alternative methodology for measuring interrater reliability (Gwet's AC1) yielded the identification of the presence of Modic changes at AC1 0.51 (95% CI 0.36-0.66), whereas agreement on the type of Modic change was AC1 0.75 (95% CI 0.66-0.83). While less common, AC1 may be preferred in the appropriate cohort to kappa as it mitigates some of the pitfalls to which kappa values may be victim. Ultimately, our results are in-line with previous reports of interrater reliability results for Modic changes in other cohorts and should serve to caution those who perform BVNA regarding interrater agreement of the imaging crux of the procedure.

The Effect of Amniotic Tissue on Spinal Interventions: A Systematic Review.

Amniotic membrane tissue has been thought to potentiate healing in many soft tissue conditions. Specifically, recent studies have shown its therapeutic potential for treatment in the setting of spinal pathologies. The purpose of this study is to thoroughly review the existing scientific literature and evidence concerning the clinical use of amniotic membrane-derived biologic agents on postoperative outcomes following spinal surgery. A systematic review was conducted following preferred reporting items for systematic reviews and meta-analyses guidelines using PubMed, Embase, and Cochrane databases up to December 2020 to identify animal and clinical studies examining the therapeutic potential for amniotic membrane tissue in the setting of spinal pathologies (including disc herniation, prevention of epidural fibrosis, and spinal fusion). Studies were broken down into 2 categories: experimental model type and the type of amnion product being analyzed. A total of 12 studies (4 clinical studies and 8 studies utilizing animal models) met inclusion criteria. Additionally, the major types of amnion product were divided into cryopreserved/freeze-dried amniotic membrane, human amniotic fluid, human amniotic membrane, cross-linked amniotic membrane, and amnion-derived epithelial cells. While heterogeneity of study design precludes definitive specific results reporting, most studies showed positive benefits on healing/outcomes with amniotic augmentation. Specifically, amnion products have shown promising effects in reducing epidural adhesions and scar tissue after spine surgery, improving spinal fusion rate and postoperative pain scores, and promoting better functional outcomes after spine surgery. A review of the limited number of reported studies revealed a wide variety of amniotic membrane preparations, treatment regimens, and indications, which limit definitive conclusions. To date, while there is no definitive clinical proof that amniotic tissues enhance tissue repair or regeneration, the aggregate results demonstrate promising basic science and outcomes potential in spinal surgery. Further study is warranted to determine whether this application is appropriate in the clinical setting. This systematic review provides a summary of the existing literature regarding the use of amniotic membrane preparations, treatment regimens, and indications within spinal surgery. With the growing popularity and utilization of biologic agents such as amniotic membrane-derived products in orthopedic and neurologic surgery, this systematic review gives physicians a concise summary on the outcomes and indications associated with amniotic membrane products.

A photoacoustics-enhanced drilling probe for radiation-free pedicle screw implantation in spinal surgery.

This article proposes a novel intra-operative navigation and sensing system that optimizes the functional accuracy of spinal pedicle screw implantation. It does so by incorporating radiation-free and multi-scale macroscopic 3D ultrasound (US) imaging and local tissue-awareness from in situ photoacoustic (PA) sensing at a clinically relevant mesoscopic scale. More specifically, 3D US imaging is employed for online status updates of spinal segment posture to determine the appropriate entry point and coarse drilling path once non-negligible or relative patient motion occurs between inter-vertebral segments in the intra-operative phase. Furthermore, a sophisticated sensor-enhanced drilling probe has been developed to facilitate fine-grained local navigation that integrates a PA endoscopic imaging component for in situ tissue sensing. The PA signals from a sideways direction to differentiate cancellous bone from harder cortical bone, or to indicate weakened osteoporotic bone within the vertebrae. In so doing it prevents cortical breaches, strengthens implant stability, and mitigates iatrogenic injuries of the neighboring artery and nerves. To optimize this PA-enhanced endoscopic probe design, the light absorption spectrum of cortical bone and cancellous bone are measured in vitro, and the associated PA signals are characterized. Ultimately, a pilot study is performed on an ex vivo bovine spine to validate our developed multi-scale navigation and sensing system. The experimental results demonstrate the clinical feasibility, and hence the great potential, for functionally accurate screw implantation in complex spinal stabilization interventions.

Evaluating opportunities for improved outpatient satisfaction in an interventional spine clinic: An analysis of Press Ganey® Outpatient Medical Practice Survey responses

ObjectiveThe Press Ganey® Outpatient Medical Practice Survey (PGOMPS) is a frequently used patient satisfaction metric comprised of provider-specific and non-provider-specific questions. The PGOMPS results are used by many administrators to improve the patient experience and are linked to physician reimbursements in some cases. This study aimed to determine the frequency of patient satisfaction for the provider-specific and non-provider-specific PGOMPS questions and their association with the likelihood of a patient recommending their provider's clinic. DesignA retrospective review. MethodsAdult patients attending a university interventional spine clinic between January 2014 and December 2019 were included in this study. We retrospectively reviewed prospectively collected patient satisfaction using PGOMPS. Data was collected within 30 days after an outpatient interventional spine clinic appointment. Satisfaction was defined as receiving a perfect total score. The frequency of perfect scores for each question was calculated. Chi-square (goodness-of-fit) analysis was performed between the number of patients who gave perfect satisfaction on all provider specific questions and the number of patients who gave perfect satisfaction for non-provider scores irrespective of their provider specific scoring. Spearman correlation between individual PGOMPS questions and the likelihood to recommend the practice question were calculated. Results53,118 patients patient encounters were included. 2078 (66.65%) provider-specific questions received perfect satisfaction versus 1121 (35.95%) with perfect satisfaction for non-provider specific questions (p ​< ​0.001). The five questions most likely to receive perfect satisfaction were: physician spoke using clear language (92.90%), physician friendliness/courtesy (82.74%), cleanliness of the practice (82.67%) likelihood to recommend practice (81.27%), and likelihood to recommend physician (80.96%). The 5 least likely were: convenience of office hours (64.30%), wait time (63.00%), ease of getting on phone (60.77%), information about delays (60.19%), and ability to get desired appointment (58.92%). Of the 10 questions that had the strongest correlation with likelihood to recommend the practice 7 were related to the physician. None of the 10 questions with the least correlation were related to the physician. ConclusionsMost interventional spine patients are satisfied with their providers and less satisfied with non-provider-related aspects of their encounters. Provider-specific factors carry the greatest influence in the patient's perceived satisfaction with the experience as a whole and likelihood to recommend the practice.

Comparison of sitting and prone positions for real-time ultrasound-guided thoracic epidural catheter placement: a randomized controlled trial

IntroductionReal-time ultrasound-guided thoracic epidural catheter placement (US-TECP) has been recently introduced. Patient’s position is associated with the success of spine interventions; however, the effects of position on the outcome of...

Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures.

Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties. The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England. We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes. We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 "wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each. We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

Update on Interventional Radiology of the Spine.

Interventional radiologists now perform spinal interventions routinely for diagnostic and therapeutic purposes. New technologies for the management of spine pathologies have emerged with promising results in terms of safety and efficacy. Interventional radiology techniques in the spine include percutaneous biopsy and therapies for intervertebral disk herniation or spinal stenosis, facet and sacroiliac joint pathologies, vertebral and sacral fractures, and metastases. These techniques can also be easily combined one with the other or to further therapeutic approaches including systemic therapies, surgical approaches, and radiotherapy. This review provides a comprehensive overview of current percutaneous imaging-guided interventional radiology techniques in the spine. It will help readers become familiar with the most common indications, learn about different technical considerations during performance, and review the available evidence. Controversies concerning new products and technical approaches are also addressed.

Interlaminar versus transforaminal epidural steroid injections: a review of efficacy and safety.

Spine intervention is an important treatment option for the management of spinal pain, and the numbers of the most representative epidural steroid injection (ESI) procedures performed are expected to increase significantly in the future along with increased life expectancy and the increasing prevalence of spinal disorders. Therefore, it is important to understand the efficacy of ESIs according to each spinal disorder they are administered to treat, and one must be familiar with the possible complications. In fact, although numerous ESI-related articles have been published, there is still considerable controversy regarding the efficacy of ESI procedures. Furthermore, due to the rarity of serious complications, most instances have been recorded in the form of case reports. In this article, we aimed to review the indications of cervical and lumbar ESIs and to compare interlaminar ESI (ILESI) and transforaminal ESI (TFESI) techniques in terms of analgesic efficacy, possible complications, and safety profiles. This article includes opinions based on the authors' experience with ESI indications and efficacy, and presents practical tips for coping with specific situations related to each complication. By combining the dedicated anatomical understanding of radiologists with image-guided interventions, ESI is expected to stand out in the rapidly expanding field of spine intervention.

Chemoprophylactic Anticoagulation 72 Hours After Spinal Fracture Surgical Treatment Decreases Venous Thromboembolic Events Without Increasing Surgical Complications

BackgroundProphylactic anticoagulation is commonly used following operative treatment of spinal fractures to prevent Venous Thromboembolism (VTE) but carries a risk of bleeding complications. The purpose of the study was to compare VTE and bleeding complications for MID (≤72h) versus LATE (>72h) chemoprophylaxis timing after spinal fracture operative intervention. MethodsThis is a retrospective review of patients treated for spinal fractures that received anticoagulation chemoprophylaxis between May 2015 and June 2019. Chemoprophylaxis initiation timing (MID vs. LATE) was the primary grouping variable. Patients with traumatic brain injury or evidence of intracranial or intraspinal bleed were excluded. Demographics, injury mechanisms, operative procedures, timing of administration of VTE prophylaxis, Injury Severity Score (ISS) and Spine Abbreviated Injury Scale (AIS), and complications including VTE and bleeding complications were collected. Predictors of VTE were identified using a binary logistic regression. ResultsEighty-eight patients (65M, 23F) met inclusion criteria. The median age was 55 years, and median Injury Severity Score (ISS) was 14. MID had 68 patients and LATE had 20. Nine patients developed VTE (6 LATE, 3 MID, p<0.01). Three patients developed bleeding complications, and all occurred in the LATE group (p=0.01). ISS (p<0.01) and GCS (p<0.01) also correlated with an increased VTE rate. ConclusionsChemoprophylactic anticoagulation at 72 hours in surgically treated spinal fracture patients demonstrates a lower VTE rate without increasing complications. VTE prophylaxis can be initiated at 72 hours following spine fixation to decrease postinjury morbidity and mortality in this high-risk patient population.

An assessment of the minimal clinically important difference for the pain disability quality-of-Life Questionnaire-Spine

ObjectiveThe Pain Disability Quality-Of-Life Questionnaire-Spine (PDQQ-S) is a validated six question patient reported outcome measure designed for usage in minimally invasive spine intervention. The purpose of this study was to determine the Minimal Clinically Important Difference (MCID) for the PDQQ-S. DesignRetrospective single arm cohort study involving 411 patients who had undergone lumbar facet and/or sacroiliac joint RFN and had completed pre-and 3-month post RFN PDQQ-S. MethodsThe MCID using both distribution and anchor-based (“Rebook RFN”; “Analgesic Requirements”) methods were calculated. ResultsThe distribution-based approach (using standard error of measurement) estimated the MCID to be −17.3 [PDQQ-S baseline mean (SD): 46.9 (7.9)]. This is supported by the anchor based approach, which calculated the MCID to be: −21.5 for rebook RFN; −11.3, -17.2 and −30.5 for mildly, moderately and dramatically decreased NSAID use respectively; and −11.7, -16.9 and −31.7 for mildly, moderately and dramatically decreased opioid use respectively. A moderate reduction in medication use was deemed to be clinically relevant. ConclusionThe MCID value for the PDQQ-S is a score reduction of 17.

The Mean ApoC1 Serum Level in Postoperative Samples from Neurosurgical Patients Is Lower than in Preoperative Samples and during Chemotherapy

Simple SummaryApolipoprotein C1 is mainly synthesized in the liver and helps in the digestion of fatty acids and in their clearance from the bloodstream. Recent reports have described the role of ApoC1 in malignant tumors of internal organs, exerting an impact on tumor growth and prognosis. Only little is known about ApoC1 in patients with diseases affecting the nervous system, so in this study, samples from neurosurgical patients were examined. A total of 219 samples from 85 patients with brain tumors was compared to 11 samples from patients undergoing non-tumor spine surgery. After drawing the blood sample, it was centrifuged to yield the serum supernatant, which was then assessed by a photometric antibody test (ELISA). The results give the concentration of ApoC1 in the probed blood in µg/mL. From a single sample, it was not possible to determine the underlying disease, such as lumbar disc herniation or brain tumor. Of note, the ApoC1 levels of glioblastoma patients fell significantly after the neurosurgical resection of the tumor and then rose again during chemotherapy. Ongoing research deals with a detailed statistical analysis to determine whether ApoC1 serum levels qualify for use as a blood biomarker for glioblastoma.Serum levels of apolipoprotein ApoC1 have been described in a number of systemic tumor entities as potential biomarkers, but little is known about ApoC1 in neurosurgical patients. A total of 230 serum samples from 96 patients were analyzed using an ELISA technique. Patient diagnoses comprised 70 glioblastomas WHO IV°, 10 anaplastic astrocytomas III°, one anaplastic oligodendroglioma III°, one oligodendroglioma II°, one diffuse astrocytoma II°, one pilocytic astrocytoma I°, and a single case of a spindle cell tumor without WHO grading, as well as 11 spinal interventions. The mean ApoC1 level of the 230 samples was 132.03 µg/mL (median 86.83, SD 292.91). In the 176 glioblastoma samples, the mean ApoC1 level was 130.0 µg/mL (median 86.23, SD 314.9), which was neither different from the whole group nor from patients with spinal interventions (215.1 μg/mL, median 63.6, SD 404.9). In the postoperative samples, the mean ApoC1 level was significantly lower (85.81 μg/mL) than in the preoperative samples (129.64 μg/mL) and in samples obtained during adjuvant chemotherapy (168.44 μg/mL). While absolute ApoC1 serum levels in a patient do not allow for the distinction between neurosurgical histological entities, future analyses will examine whether the time course of ApoC1 in an individual patient can be related to certain treatment stages.

P954: ESTABLISHING THE NATIONAL INSTITUTE FOR HEALTH RESEARCH (NIHR) HEALTH INFORMATICS COLLABORATIVE (HIC) MULTIPLE MYELOMA (MM) REGISTRY

Background: Real world data provides unique insights into the natural history of MM, resource utilisation, adherence to standards and outcomes of treatments outside clinical trials. However, the quality of such initiatives can be poor due to the need for manual data entry, inability to integrate multiple data sources, lack of harmonisation of data across centres and limited generalisability due to centre bias. Exemplar registries collate and transform multidisciplinary routinely collected data from Electronic Health Records (EHRs) to a common data language allowing integration, analysis and expansion. Aims: To develop a secure national MM registry beginning with a three site pilot. Methods: Potential registry providers were evaluated against the following criteria: previous experience, infrastructure and technical capability, data governance, compliance with legal standards and cost effectiveness. The platform required ethical and data sharing approvals. A common data model was investigated and a myeloma focused multidisciplinary dataset was designed and mapped to source data. Data extraction, transformation and analysis is planned. Results: 8 providers were assessed for suitability. The NIHR HIC was chosen due to its established data sharing network across 30 UK sites and overarching governance framework. This platform permitted the establishment of harmonised data flow, comparable across sites and retaining clinical interpretability. A minimal myeloma dataset of routinely collected information was agreed by clinicians and data scientists to contain the following fields: baseline and disease characteristics including imaging findings eg: extramedullary/paramedullary disease, skeletal/spinal disease, comorbidities, mode of presentation, cytogenetics, treatments including chemotherapy, stem cell transplants/CAR-T cells, spinal interventions, anti-infectives, bisphosphonates and other supportive care. Each variable was mapped to identify the location of raw data in the EHR, its format and suitability for extraction. For unstructured data, eg: cytogenetics and imaging reports, natural language processing is being developed to extract key fields. To enable harmonisation of data from different systems, data is transformed into a common data model. The Observational Medical Outcomes Partnership common data model (OMOP CDM) was chosen as it provided a framework for systematic analysis of data from disparate data sources, typical of those held within health care information systems. This model allows for international benchmarking and collaboration for research. OMOP CDM maps commonly used coding systems and vocabularies, eg ICD-10, SNOMED-CT into standard concepts permitting raw data entering the registry to be standardised into a research ready format that is person-centric, disease agnostic and syntactically and semantically defined. Anonymised data from multiple sites will be electronically transferred to a ISO27001 certified, GDPR compliant UCL data safe haven for analysis. Oversight is provided by the Steering Committee of clinicians, data scientists, myeloma patients and Myeloma UK with patient involvement at every step. Data will be analysed to answer 3 initial themes (Image 1), and extended further to include control data for Health Technology Appraisals. To date we have successfully identified an initial cohort of over 4000 myeloma cases since 2015. Image:Summary/Conclusion: The NIHR HIC Myeloma registry represents a research ready platform to integrate and analyse UK wide real word data. Detailed data analysis and progress in answering the initial 3 themes is ongoing. Funding: Myeloma UK & NIHR

The usefulness of vertebral needle targeting simulation training system using ray-summation imaging: experimental study

PurposeUsing the multi-detector computed tomography and related three-dimensional imaging technology, we developed a vertebral needle targeting simulation training system named spinal needling intervention practice using ray-summation imaging (SNIPURS). Herein, we assessed the utility of SNIPURS by evaluating changes in the learning curves of SNIPURS trainees.MethodsTwenty-one examinees were enrolled: seven experienced operators (expert group), seven trainees with coaching (coaching group), and seven trainees without coaching (non-coaching group). They performed six tests of vertebral needle targeting simulation on the workstation-generated spinal ray-summation images of six patients with vertebral fractures. In each test, they determined the bilateral trans-pedicular puncture points and angles on two thoracic and two lumbar vertebrae on ray-summation imaging (i.e., 8 simulations per test). The coaching group received coaching by a trainer after Tests 1 and 4, while the others did not. Scores were given based on the trans-pedicular pathway (1 point) or not (0 point). Eight virtual needles were evaluated in each of Tests 1–6.ResultsAmong the three groups, the expert group had the highest average scores on Tests 1–4 (expert: 3.86, 6.57, 7.43, and 7.57; coaching: 1.86, 6.14, 6, and 6.29; and non-coaching: 1.14, 4.14, 4.71, and 4.86). The coaching group’s scores caught up with the expert groups’ average scores on Tests 5 and 6, whereas those of the non-coaching group did not (expert and coaching: 7.86 and 8.00, non-coaching: 5.86 and 7.14). All examinees in the expert and coaching groups achieved a perfect score on the final Test 6, whereas three of the seven non-coaching trainees did not.ConclusionSNIPURS might be suitable for vertebral needle targeting training. The coaching provided during SNIPURS training helped the trainees to acquire the spinal puncture techniques in PVP.

Risk of ventriculoperitoneal shunt malfunction in operatively treated early onset spinal deformity.

Ventriculoperitoneal (VP) shunt placement is a common neurosurgical procedure performed in patients with early onset scoliosis (EOS). To provide insight into the risks of spine lengthening operations, we investigate the rate of VP shunt complications in patients with EOS undergoing spinal deformity correction interventions. A retrospective review was performed of all patients with EOS at a single institution undergoing spinal deformity correction procedures from 2007 to 2018. Patients having undergone VP shunt implantation prior to deformity correction were included. A minimum of 2-year follow-up was required for inclusion. Clinical records and imaging studies were reviewed. Nineteen patients with VP shunts underwent Vertical Expandable Prosthetic Titanium Rib (VEPTR) implantation for treatment of early onset spinal deformity. The mean age at shunt placement and spine instrumentation surgery was 13.7months (1day to 13years) and 6.1years (0.5-15.1) respectively. The diagnoses associated with shunt implantation were: 12 spina bifida, 3 structural defects or obstructions, 2 intraventricular hemorrhage, 1 cerebral palsy, and 1 campomelic dwarfism. During the first 2years following rib-based insertion, there was a mean of 2.5 expansion/revision procedures (0-5) with no shunt-related complications. The mean length of follow-up in this series was 7.0years (2.6-13.2). A total of three (16%) patients required shunt revision following their rib-based device insertion, two patients with proximal shunt malfunctions and one with a mid-catheter breakage, at 2.4, 2.6, and 5.6years, respectively, after rod implantation (Fig.2). Each of these shunt revisions occurred more than 50days following an expansion procedure (1.9, 2.9, and 5.7months, respectively). Growing instrumentation procedures in EOS are associated with low risk for post-operative shunt complications in patients with ventriculoperitoneal shunts. There were no shunt revision procedures performed in the first 2years following rib-based device insertion. Sixteen percent of patients went on to require a shunt revision at some point during their follow-up, which is comparable to the baseline rate of shunt revision in non-EOS patients. IV, Case series.