Metastatic Spine Tumour Surgery Research Articles

Evaluation of the Feasibility of Transfusing Leucocyte Depletion Filter (LDF) Processed Intra-Operative Cell Salvage (IOCS) Blood in Metastatic Spine Tumour Surgery (MSTS): Protocol for a Non Randomised study (Preprint)

Evaluation of the Feasibility of Transfusing Leucocyte Depletion Filter (LDF) Processed Intra-Operative Cell Salvage (IOCS) Blood in Metastatic Spine Tumour Surgery (MSTS): Protocol for a Non Randomised study (Preprint)

A Useful Model for Predicting Intraoperative Blood Loss in Metastatic Spine Tumor Surgery.

A retrospective study was performed. As predictors of intraoperative blood loss have not yet been well defined, the objective of the present study is to develop a model to predict the amount of intraoperative blood loss in metastatic spine tumor surgery. Massive blood loss is a huge challenge in metastatic spine tumor surgery. Misjudgment of intraoperative blood loss in preoperative planning may result in disastrous consequences. Enrolled in this retrospective analysis were 392 patients who received 423 surgeries of vertebrectomy and reconstruction in our hospital between 2011 and 2017. Risk factors for high-volume blood loss were identified by univariate and multivariate linear regression. The optimal regression model was selected to predict the amount of intraoperative blood loss. Correlation analysis between predicted and actual blood loss in the test cohort was performed to verify the performance of the new model. The overall mean blood loss was 1756±1218 mL, with spinal metastases from thyroid cancer most prominent, followed by renal cancer. The model was developed based on 5 independent risk factors influencing intraoperative blood loss: primary tumor, tumor site, level of instrumentation, level of vertebrectomy, and resection method. In the test cohort, the correlation coefficient (r) between predicted and actual blood loss was 0.606. This study presented a relatively reliable method to predict the amount of intraoperative blood loss in metastatic spine tumor surgery, which may help surgeons address blood loss-related issues in preoperative planning.

Therapeutic Impact of Percutaneous Pedicle Screw Fixation on Palliative Surgery for Metastatic Spine Tumors.

Background:Percutaneous pedicle screw (PPS) fixation has been introduced into palliative surgery for metastatic spine tumors; however, the therapeutic effects of PPS on the outcomes of multidisciplinary treatment for such tumors are unclear. Therefore, the therapeutic impact of PPS was investigated among patients with metastatic spine tumors and with revised Tokuhashi scores of ≤8.Materials and Methods:A total of 47 patients who underwent conventional palliative surgery (posterior decompression and stabilization, 33; posterior stabilization alone, 14) before the introduction of PPS and 38 patients who underwent PPS (posterior decompression and stabilization, 19; posterior stabilization alone, 19) were included. Surgical stress (operative time, blood loss, complications, etc.) and treatment outcomes (postoperative survival time, visual analog scale scores, Frankel classification, and the Barthel index at the final followup) were compared between the conventional and PPS groups.Results:The age of the indicated patients significantly increased after the introduction of PPS (P < 0.05). Regarding posterior decompression and stabilization, there were no significant intergroup differences in surgical stress or treatment outcomes. As for posterior stabilization alone, there were significant preoperative differences in various parameters between the conventional and PPS groups (P < 0.01) and also significant postoperative intergroup differences between surgical stress and treatment outcomes (P < 0.01).Conclusions:For patients with early-stage metastatic spine tumors, the use of PPS-based posterior stabilization combined with multidisciplinary adjuvant therapy has changed the age range of the patients indicated for surgery and caused significant improvements in surgical stress, postoperative survival time, and Barthel index.

Intraoperative Neuromonitoring (IONM): Is There a Role in Metastatic Spine Tumor Surgery?

A retrospective design. We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS). IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS. A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG). The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively. Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression. 3.

Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery.

To review the current status of salvaged blood transfusion (SBT) in metastatic spine tumour surgery (MSTS), with regard to its safety and efficacy, contraindications, and adverse effects. We also aimed to establish that the safety and adverse event profile of SBT is comparable and at least equal to that of allogeneic blood transfusion. MEDLINE and Scopus were used to search for relevant articles, based on keywords such as “cancer surgery,” “salvaged blood,” and “circulating tumor cells.” We found 159 articles, of which 55 were relevant; 20 of those were excluded because they used other blood conservation techniques in addition to cell salvage. Five articles were manually selected from reference lists. In total, 40 articles were reviewed. There is sufficient evidence of the clinical safety of using salvaged blood in oncological surgery. SBT decreases the risk of postoperative infections and tumour recurrence. However, there are some limitations regarding its clinical applications, as it cannot be employed in cases of sepsis. In this review, we established that earlier studies supported the use of salvaged blood from a cell saver in conjunction with a leukocyte depletion filter (LDF). Furthermore, we highlight the recent emergence of sufficient evidence supporting the use of intraoperative cell salvage without an LDF in MSTS.

Factors influencing extended hospital stay in patients undergoing metastatic spine tumour surgery and its impact on survival

Metastatic spine tumour surgeries (MSTS) are indicated for preservation or restoration of neurological function, to provide mechanical stability and pain alleviation. The goal of MSTS is to improve the quality of life of the patients with spinal metastases and rarely for oncological control which is usually achieved by adjuvant therapies. Hence outcome measures such as length of stay (LOS) and rate of complications after MSTS are important indicators of quality but there is limited literature evidence for the same. We carried out a retrospective study to determine the incidence and the factors influencing normal (nLOS) and extended length of stay (eLOS) after MSTS. Data of 220 consecutive patients who underwent MSTS between 2005 and 2015 were retrieved from hospital electronic records. The preoperative, intraoperative and postoperative variables, discharge destinations as well as socioeconomic factors were analyzed. eLOS defined as positive when the LOS exceeded the 75th percentile for this cohort, was the key outcome indicator. Univariate and multivariate logistic regression analyses were performed to determine the predictive factors of eLOS. The overall median LOS was 7 days (1–30 days) and 55 patients had eLOS (LOS ≥ 11 days). Multivariate analysis revealed that significant variables independently associated with eLOS were instrumentation >9 spinal segmental levels (OR 2.89, 95% CI 1.1–7.5, p = 0.032) and presence of postoperative complications (OR 3.68, 95% CI 1.85–7.30, p < 0.001). Metastatic tumours other than breast, prostate and lung have lesser risk of eLOS (OR 0.31, 95% CI 0.14–0.70, p = 0.004). Survival estimates show that patients with eLOS have shorter survival than patients with nLOS (Crude HR 1.81, 95% CI 1.13–2.89, p = 0.003).

Basic concepts in metal work failure after metastatic spine tumour surgery.

The development of spinal implants marks a watershed in the evolution of metastatic spine tumour surgery (MSTS), which has evolved from standalone decompressive laminectomy to instrumented stabilization and decompression with reconstruction when necessary. Fusion may not be feasible after MSTS due to poor quality of graft host bed along with adjunct chemotherapy and/or radiotherapy postoperatively. With an increase in the survival of patients with spinal tumours, there is a probability of an increase in the rate of implant failure. This review aims to help establish a clear understanding of implants/constructs used in MSTS and to highlight the fundamental biomechanics of implant/construct failures. Published literature on implant failure after spine surgery and MSTS has been reviewed. The evolution of spinal implants and their role in MSTS has been briefly described. The review defines implant/construct failures using radiological parameters that are practical, feasible, and derived from historical descriptions. We have discussed common modes of implant/construct failure after MSTS to allow further understanding, interception, and prevention of catastrophic failure. Implant failure rates in MSTS are in the range of 2-8%. Variability in patterns of failure has been observed based on anatomical region and the type of constructs used. Patients with construct/implant failures may or may not be symptomatic and present either as early (<3months) or late failures (>3months). It has been noted that not all the implant failures after MSTS result in revisions. Based on the observed radiological criteria and clinical presentations, we have proposed a clinico-radiological classification for implant/construct failure after MSTS.

Metastatic spine tumor surgery: does perioperative blood transfusion influence postoperative complications?

The question of independent association between allogeneic blood transfusion (ABT) and postoperative complications in cancer surgeries has been controversial and remains so. In metastatic spine tumor surgery (MSTS), previous studies investigated the influence of ABT on survival, but not on postoperative complications. We aimed to evaluate the influence of perioperative ABT on postoperative complications and infections in patients undergoing MSTS. This retrospective study included 247 patients who underwent MSTS at a single tertiary institution between 2005 and 2014. The outcome measures were postoperative complications and infections within 30 days after MSTS. Multivariate logistic regression analyses were performed to assess influence of blood transfusion on the outcomes after adjusting for potential confounders. Of 247 patients, 133 (54%) received ABT with overall median (range) of 2 (0-10) units. The adjusted odds of developing any postoperative complication was 2.27 times higher in patients with transfusion (95% confidence interval [CI], 1.17-4.38; p = 0.01) and 1.24 times higher odds per every unit increase in blood transfusion (95% CI, 1.05-1.46; p < 0.01). Exposure to blood transfusion also increased the odds of having overall postoperative infections (odds ratio, 3.58; 95% CI, 1.15-11.11; p = 0.02) and there were 1.24 times higher odds per every unit increase in transfusion (95% CI, 1.01-1.54; p = 0.04). This study adds evidence to the literature implicating ABT to be influential on postoperative complications and infections in patients undergoing MSTS. Appropriate blood management measures should, therefore, be given a crucial place in the care of these patients so as to reduce any putative effect of blood transfusion.

The safety, efficacy, and cost-effectiveness of intraoperative cell salvage in metastatic spine tumor surgery

Background ContextMetastatic spine tumor surgery (MSTS) is associated with substantial blood loss, therefore leading to high morbidity and mortality. Although intraoperative cell salvage with leukocyte depletion filter (IOCS-LDF) has been studied as an effective means of reducing blood loss in other surgical settings, including the spine, no study has yet analyzed the efficacy of reinfusion of salvaged blood in reducing the need for allogenic blood transfusion in patients who have had surgery for MSTS. PurposeThis study aimed to analyze the efficacy, safety, and cost-effectiveness of using IOCS-LDF in MSTS. Study DesignThis is a retrospective controlled study. Patient SampleA total of 176 patients undergoing MSTS were included in the study. MethodsAll patients undergoing MSTS at a single center between February 2010 and December 2014 were included in the study. The primary outcome measure was the use of autologous blood transfusion. Secondary outcome measures included hospital stay, survival time, complications, and procedural costs. The key predictor variable was whether IOCS-LDF was used during surgery. Logistic and linear regression analyses were conducted by controlling variables such as tumor type, number of diseased vertebrae, approach, number and site of stabilized segments, operation time, preoperative anemia, American Society of Anesthesiologists (ASA) grade, age, gender, and body mass index (BMI). No funding was obtained and there are no conflicts of interest to be declared. ResultsData included 63 cases (IOCS-LDF) and 113 controls (non–IOCS-LDF). Intraoperative cell salvage with LDF utilization was substantively and significantly associated with a lower likelihood of allogenic blood transfusion (OR=0.407, p=.03). Intraoperative cell salvage with LDF was cost neutral (p=.88). Average hospital stay was 3.76 days shorter among IOCS-LDF patients (p=.03). Patient survival and complication rates were comparable in both groups. ConclusionsWe have demonstrated that the use of IOCS-LDF in MSTS reduces the need for postoperative allogenic blood transfusion while maintaining satisfactory postoperative hemoglobin. We recommend routine use of IOCS-LDF in MSTS for its safety, efficacy, and potential cost benefit.

47 - Metastatic spine tumour surgery: does perioperative blood transfusion influence postoperative complications?

47 - Metastatic spine tumour surgery: does perioperative blood transfusion influence postoperative complications?

50 - Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery?

50 - Perioperative blood transfusion: does it influence survival and cancer progression in metastatic spine tumor surgery?

Changing the Adverse Event Profile in Metastatic Spine Surgery: An Evidence-Based Approach to Target Wound Complications and Instrumentation Failure.

Systematic review. To identify risk factors and preventive methods for wound complications and instrumentation failure after metastatic spine surgery. We focused on two postoperative complications of metastatic spine tumor surgery: wound complications and instrumentation failure and preventive measures. We performed a systematic review of the literature from 1980 to 2015. The articles were analyzed for the presence of documented infection and/or wound complications and instrumentation failure. Forty articles met our inclusion criteria for wound complications and prevention. There is very low level of evidence that preoperative radiation, preoperative neurological deficit, revision procedures, and posterior approaches can contribute to wound complications (infections, wound dehiscence). There is very low level of evidence that plastic surgery soft tissue reconstruction, intrawound vancomycin powder, and percutaneous pedicle screws may prevent postoperative wound complications. Fourteen articles met our inclusion criteria for instrumentation failure. There is very low level of evidence that constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resection can contribute to implant failures. • For patients undergoing revision metastatic spine tumor surgery, plastic surgery should perform the soft tissue reconstruction (strong recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, plastic surgery may perform immediate soft tissue reconstruction (weak recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, intrawound vancomycin can be applied to decrease the risk of postoperative wound infections (weak recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, percutaneous pedicle screws can be placed to decrease the risk of postoperative wound complications (weak recommendation/very low quality of evidence).• Instrumentation failure risk factors include constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resections (weak recommendation/very low quality of evidence). N/A.

Evidence-Based Review and Survey of Expert Opinion of Reconstruction of Metastatic Spine Tumors.

Systematic review and consensus expert opinion. To provide surgeons and other health care professionals with guidelines for surgical reconstruction of metastatic spine disease based on evidence and expert opinion. The surgical treatment of spinal metastases is controversial. Specifically two aspects of surgical reconstruction are addressed in this study: (i) choice of bone graft used during surgery for metastatic spine tumors and (ii) the design of reconstruction or construct to stabilize. A systematic review of the available medical literature from 1980 to 2015 was conducted, and combined with consensus expert opinion from a recent survey of spine surgeons who treat metastatic spine tumors. There is very little evidence in the literature to provide guidance on the use of bone graft in metastatic tumor reconstruction. There is little evidence in the literature to support the preferential use of one graft type over the other. Approximately, 41% of respondents said they used bone graft or bone graft substitutes to accomplish fusion. There were 17 studies that described the use of a prefabricated prosthetic, 10 studies describing the use of polymethyl methacrylate (PMMA) bone cement, and only three studies describing the use of bone graft for anterior column reconstruction. The use of structural allograft was most popular among the experts for anterior reconstruction, followed by cage reconstruction, and PMMA bone cement. Achieving bony union may be of importance for the maintenance of spinal stability in the long term after reconstruction. Whether bony union is required for patients with shorter life expectancies is debatable. The literature supports the use of anterior reconstruction with either a prefabricated prosthetic or PMMA bone cement. It also supports the use of an anterior construct reinforced with bilateral posterior instrumentation when performing a three-column reconstruction. N/A.

Evaluation of the safety of Intraoperative Salvaged Blood by using Microwell based Culture

Introduction Intraoperative cell salvage (IOCS) in metastatic spine tumor surgery (MSTS) is a novel alternative for addressing the potential side effects related to ABT. However, it has not been widely adopted in oncological surgery due to the hypothetical concern of reinfusing tumor cells to the patients. Despite the emerging evidence of the safety of IOCS especially in combination with leucocyte depletion filter (LDF), most surgeons are still doubtful about using IOCS during oncological surgery. We aimed to evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating cancer cells from blood salvaged during metastatic spine tumor surgery (MSTS). We hypothesized that tumor cells, even if left in the salvaged blood, are incapable of seeding and replicating due to potential damage to the cell membrane or the contents during suction, centrifugation and filtration during cell saver processing and hence, making the salvaged blood safe to be reinfused. Methods Patients with known primary epithelial tumor, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at five different stages during surgery: Stage A: venous blood from the patient during induction by anaesthetist, Stage B: venous blood from the patient during maximum tumor manipulation by the surgeons, Stage C:blood from operative field prior to IOCS processing, Stage D: salvaged blood after IOCS processing and stage E: salvaged blood after IOCS-LDF processing. Blood samples(5 ml) were taken at each stage. Samples were sent for preparation of microwell-based culture assay for detection of primary circulating tumor cells (CTCs). Results We recruited 13 patients of which 12 were included in final analysis. There were 7 females and 5 males. The median age of the patients was 61 years (range: 48 - 76 years). The commonest primary tumor was lung, followed by breast, hepatocellular and renal cell carcinoma. The median blood loss was 800 ml (range: 300 – 1500 ml). Analysis of the cultured samples showed that clusters or CK+ CTCs (cytokeratin positive CTCs) were found in the samples taken from stage A in three patients, stage B in three patients and stage C in one patient. However, none of the samples D and E from any patients generated viable tumor clusters or CK+ CTCs after culture. Conclusions The present study proved that our hypothesis was correct. The findings supported the notion that IOCS-LDF combination works effectively in eliminating/destroying tumor cells from salvaged blood. The absence of viable CTCs in the samples taken from salvaged blood (stage D) provided the fact that salvaged blood even without filtration is safe for reinfusion in cancer patients. This IOCS technique can be applied in MSTS and even musculoskeletal oncological surgery. The concept can then be extended to other oncological surgeries in general with further appropriate clinical studies.

Preoperative Embolization in Spinal Tumour Surgery

Introduction Preoperative embolization has been shown to be effective in reducing intraoperative blood loss during metastatic spinal tumor surgery. However, the majority of studies investigating preoperative embolization for spinal metastases have preferentially selectedsecondaries fromrenal and thyroid as these are highly vascularized tumors. There is paucity of literature describing utility of embolization in other tumors. We aimed to determine the effect of preoperative embolization on intraoperative blood loss indifferent spinal tumors by type of surgical approaches. Materials and Methods We retrospectively evaluated 221 patients undergoing surgery for primary or metastatic spine tumors. Patients were analyzed for the effect of embolization agents, extent, level of embolization and timing between embolization &amp; surgery, on estimated blood loss. Estimated blood loss and transfusion requirements were compared between embolized and non-embolized cases for different types of spinal tumor (metastatic lung, breast, renal, hepatocellular, thyroid, other epithelial tumors, myeloma/lymphoma and primary spine tumors) and surgical approaches (Type I: Cervical spine surgery either anterior and/or posterior stabilization with or without corpectomy, Type II: Thoracolumbar posterior instrumentation and decompression, and Type III: Thoracolumbar corpectomy). Results Preoperative embolization was performed in 48 patients. Hypervascular angiographic appearance was found in 22 (46%) and capillary blush in 26 (54%) embolized patients. Total embolization (&gt;80% reduction of tumor blush) was achievable in more than half of the embolized patients (61%), and less amount of blood loss was observed in these patients (median blood loss = 900ml) compared with those who achieved partial (&lt;50%) and subtotal (50–90%) embolization (1600ml and 1350ml respectively). Blood loss was also lower in those who achieved proximal embolization and those who underwent surgery between 13–24 hours after embolization. When stratified by type of tumor and surgical approaches, blood loss and transfusion requirement were lower in embolized cases of spinal secondaries from HCC &amp; thyroid; and primary spine tumors. In multivariate linear regression, after adjusting for tumor type, type of surgical procedure, invasiveness index, preoperative haemoglobin and operative time, there were no significant differences in the blood loss as well as blood transfusion units between embolized and non-embolized groups. Conclusions Success of embolization in reducing blood loss depends on the extent of embolization, which should be total; and time interval between embolization and index surgery, which should be within 13–24 hours. Preoperative embolization is a useful modality in decreasing intraoperative blood loss in cases of spinal metastases from HCC, thyroid and primary spine tumors.

The safety, efficacy and cost-effectiveness of intraoperative cell-salvage in metastatic spine tumour surgery

BACKGROUND CONTEXT: This is the first comparative study in the literature evaluating efficacy, safety and cost-effectiveness of using intraoperative cell salvage with leucocyte depletion filter (IOCS-LDF) in metastatic spine tumour surgery (MSTS).

Flowcytometric evaluation of intraoperative salvaged blood filtered with leucocyte depletion filter in metastatic spine tumour surgery

Flowcytometric evaluation of intraoperative salvaged blood filtered with leucocyte depletion filter in metastatic spine tumour surgery

Evaluation of the safety of using intra-operative salvaged blood in metastatic spine tumour surgery: using microwell technique

Evaluation of the safety of using intra-operative salvaged blood in metastatic spine tumour surgery: using microwell technique

Are we ready for transfusing intraoperative salvaged blood in metastatic spine tumour surgery

Are we ready for transfusing intraoperative salvaged blood in metastatic spine tumour surgery

Versatility of percutaneous pedicular screw fixation in metastatic spine tumour surgery

BackgroundMinimally invasive surgery has been evolved to address the problems associated with metastatic spine diseases (MSD). Posterior percutaneous spinal fixation (PPSF) is one of the main modal...