Symptomatic Spine Research Articles

Outcome of spine surgery in the context of spinal metastatic disease: The National Surgical Quality Improvement Program

Background: Spinal metastases are the third most common site of metastasis, with around 10% of cancer patients experiencing symptomatic spine involvement. Despite poor overall survival, recent advances in targeted therapies and minimally invasive surgical techniques have made surgery a more viable option for managing metastatic spine disease. Objective: Our study aims to identify perioperative risk factors associated with poor outcomes following spine surgery in the setting of spinal cord metastasis. Methods: We used the National Surgical Quality Improvement Program data. Patients with metastatic spine disease undergoing spine surgery were identified. Our primary outcome measure was 30-day morbidity and mortality after surgery. Our secondary outcome was prolonged hospital stay. Logistic regression model for each outcome based on individual characteristics was developed. Results: A total of 2109 patients were included. The 30-day morbidity and mortality rates were 19.1%. Significant predictors included smoking, more than 10% body weight loss, surgical urgency, dependent status, and preoperative albumin levels. In addition, 28.6% of patients experienced a prolonged hospital stay, with significant predictors including chemotherapy, surgical urgency, dependent status, preoperative hematocrit, neurological deficits, preoperative albumin levels, and surgical complexity. Conclusion: Our study provides valuable insights into the risk factors associated with mortality, morbidity, and prolonged hospital stay in patients with spinal cord metastasis undergoing spine surgery. These identified factors can be instrumental in assisting clinicians with risk stratification, preoperative optimization, and postoperative care planning, ultimately improving patient outcomes. Further research and validation of these predictive models are warranted to ensure their generalizability and applicability in clinical practice.

Establishing a protocol to increase racial/ethnic minority enrollment on an active radiation oncology randomized clinical trial.

TPS1638 Background: In the United States (US), underrepresented racial/ethnic groups lack ample enrollment in clinical trials, yielding ungeneralizable trial results. Barriers to increasing minority enrollment include decreased awareness of clinical trials, lack of access, financial burden and toxicity, medical system mistrust, and discordant physician-patient demographics. The ongoing Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN) clinical trial (NCT05617716) has a study design to actively accrue minority patients. We present our protocol addressing key targets to increase minority enrollment on this randomized, phase II clinical trial. Methods: Adults with evidence of symptomatic spine metastases are eligible. Baseline demographics (including race/ethnicity) are reported for statistical analysis. Our protocol seeks to minimize barriers to minority enrollment and targets four key areas. Access to care: SPORTSMEN involves institutions located in zip codes with diverse ethnic populations, presently located in regions 46% and 70% African American. Clinical trial design: SPORTSMEN has a prespecified goal of accruing patients to mirror US census representation. The rate of minority enrollment will be reviewed periodically at the discretion of the Data Safety and Monitoring Board. Community outreach and engagement: The trial team will engage with local health care systems to create an alliance within different oncology specialties to provide the basis and benefit for SPORTSMEN and patient-centered education on eligibility criteria, rationale, and intended outcomes. Our principal focus will be providers in prostate, breast, and lung cancers as minorities with these primary site malignancies have a higher propensity to be trial-eligible. Furthermore, we understand the historical mistrust of minorities for the medical community. Therefore, we will engage local grassroot organizations such as churches, community outreach centers, and social clubs to increase awareness of clinical trials and to help foster trust. Financial burden and toxicity: SPORTSMEN does not have direct enrollment costs. A short-course treatment regimen is used to minimize the number of treatment visits required allowing for decreased resources for travel, time lost at work, and additional childcare or eldercare needs. Financial toxicity will be objectively quantified using the validated COST-Functional Assessment of Chronic Illness Therapy survey. Increasing clinical trial diversity is a challenge that must be addressed with meaningful intent to present robust Level 1 data that broadens the understanding of treatment response in all demographics. Our protocol takes a patient-centered approach to achieve the objective of concordant racial/ethnic representation in a randomized clinical trial. Clinical trial information: NCT05617716 .

Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial

BackgroundEarly palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year.MethodsThis is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0–2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20–30 Gy of radiation in 2–10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05.DiscussionThe results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy.Trial registrationClinicalTrials.Gov NCT05534321. Registered September 9, 2022.Trial statusVersion 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.

Insurance Denial of Care for Randomized Controlled Trial-Eligible Patients: Incidence and Success Rate of Peer-To-Peer Authorization in Allowing Patients to Remain Trial-Eligible.

Insurance denials for clinical trials serve as a pertinent barrier for patients to remain trial-eligible, thus hindering the development of therapies and the overall advancement of health care. We present results from an ongoing oncology randomized clinical trial regarding insurance denials and peer-to-peer authorization (P2PA) success rate in allowing patients to remain trial-eligible. The ongoing Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms Phase II trial randomizes spine cancer patients to treatment with spine radiosurgery/stereotactic body radiation therapy (SBRT) versus conventional external beam radiation therapy (EBRT). Trial-eligible patients during the first 3 months of enrollment are examined to determine whether the option of SBRT was denied by their insurance. Advocacy for overcoming SBRT denial in P2PA centered on SBRT being recommended as a preferred treatment modality in the National Comprehensive Cancer Network guidelines, and the recent level I evidence demonstrating the advantages of SBRT over EBRT for symptomatic spine cancer. Of 15 trial-eligible patients, 3 (20%) experienced insurance denials for SBRT. P2PA resulted in the reversal of denials in all 3 patients, allowing each to remain trial-eligible for randomization between SBRT and cEBRT. Despite a clinical oncologic treatment modality for which recent Level 1 evidence is available, the insurance denial rate was 20%. A vigilant P2PA strategy focusing on highlighting National Comprehensive Cancer Network guidelines and the supporting Level 1 evidence resulted in a very high rate of reversing initial denial.

Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN): a randomized phase II study protocol.

Approximately 40% of patients with metastatic cancer will have spinal metastatic disease. Historically treated with external beam radiation therapy (EBRT) with limited durability in pain control, the increased lifespan of this patient population has necessitated more durable treatment results via spine radiosurgery/stereotactic body radiation therapy (SBRT). The goal of this study is to assess three-month pain freedom rates via the Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN) randomized trial. This study is a prospective randomized three-arm phase II trial which will recruit patients with symptomatic spine metastases. All patients will be randomized to standard-of care SBRT (24 Gy in 2 fractions), single-fraction SBRT (19 Gy in 1 fraction), or EBRT (8 Gy in 1 fraction), with the primary endpoint of three-month pain freedom (using the Brief Pain Inventory). We expect that SPORTSMEN will help definitively answer the efficacy of spine SBRT versus EBRT for achieving pain freedom, while defining the safety and efficacy of 19 Gy single-fraction spine SBRT. Local control will be defined according to Spine Response Assessment in Neuro-Oncology (SPINO) criteria. This is the first phase II trial to objectively assess optimal spine SBRT dosing in the treatment of symptomatic spine metastatic disease, while assessing spine SBRT versus EBRT. Findings should allow for better determination of the efficacy of two-fraction spine SBRT versus EBRT in the United States, as well as for the novel single-fraction 19 Gy spine SBRT regimen in patients with symptomatic spine metastases. Clinicaltrials.gov identifier: NCT05617716 (registration date: November 14, 2022).

Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated.Each patient follows his own “personal” sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high “ASA” score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention.

125 Survival Analysis by Molecular Subtype for Surgically Treated Breast Cancer Spine Metastases

INTRODUCTION: Breast cancer spine metastases are a devastating and pervasive clinical problem. Discoveries in tumor biology and the pathophysiology of metastatic disease have expanded systemic treatment options for metastatic breast cancer. The implications of evolving treatment strategies should inform the surgical treatment of spine metastases and the predicted prognosis to guide personalized approaches. METHODS: This is a multi-institutional, retrospective, observational cohort study of patients who underwent spine surgery for symptomatic breast cancer spine metastases from 2008-2020. We studied overall survival, stratified by breast cancer molecular subtype and calculated hazard ratios adjusting for demographics, tumor characteristics, treatments, and laboratory values. We tested the performance of established models (Tokuhashi, Bauer, SORG, NESMS) to predict and compare all-cause mortalities using time-dependent performance metrics. RESULTS: A total of 98 patients surgically treated for breast cancer spine metastases were identified. The 1-year probabilities of survival for HR+, HR+/HER2+, HER2+, and TNBC were 63%, 83%, 0%, and 12% (P &lt;0.001). Postoperative chemotherapy and endocrine therapy were associated with prolonged survival. The SORG prognostic model had the highest discrimination. The performance of all prognostic scores improved when preoperative molecular data was considered in addition to postoperative systemic treatment data. CONCLUSIONS: Advanced HR+, HR+/HER2+ breast cancer portended significantly longer overall survival compared with HER2+ and TNBC tumors after surgery for symptomatic spine metastases. Hormone receptor status and postoperative systemic therapy should be considered in prediction models for a more accurate assessment of prognosis.

Biological and Clinical Aspects of Metastatic Spinal Tumors.

Simple SummarySpine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Our literature review aimed to describe the up-to-date knowledge about the molecular pathways and biomarkers engaged in the spine’s metastatic processes. Moreover, we described current data regarding bone-targeted treatment, the emerging targeted therapies, radiotherapy, and immunotherapy used for the treatment of spine metastases. We hope that knowledge comprehensively presented in our review will contribute to the development of novel drugs targeting specific biomarkers and pathways. The more we learn about the molecular aspects of cancer metastasis, the easier it will be to look for treatment methods that will allow us to precisely kill tumor cells.Spine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Thanks to continuous research, there appears more and more detailed knowledge about cancer and metastasis, but these transformations are extremely complicated, e.g., due to the complexity of reactions, the variety of places where they occur, or the participation of both tumor cells and host cells in these transitions. The right target points in tumor metastasis mechanisms are still being researched; that will help us in the proper diagnosis as well as in finding the right treatment. In this literature review, we described the current knowledge about the molecular pathways and biomarkers engaged in metastatic processes involving the spine. We also presented a current bone-targeted treatment for spine metastases and the emerging therapies targeting the discussed molecular mechanisms.

The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment.

In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters. A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05. 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3mm ± 6.5mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005). Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.

Functional Ability Classification Based on Moderate and Severe Kinesophobia and Demoralization Scores in Degenerative Spine Patients.

A prospective cohort study. To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors. Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress. Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis. Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts. This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.

The Role of Stabilization-Free Microsurgical Decompression in the Surgical Treatment of Spinal Metastases

Symptomatic spine metastases are found in about 10% of patients with cancer. As the long-term survival of patients with carcinoma rises, the number of patients with symptomatic spine metastases is also increasing. In our tertiary referral center, patients usually present rapidly progressive neurologic disorders, which require an urgent treatment decision. Treatment options include extensive 360° stabilizations. These complex interventions are not always readily available. We examined the extent to which the patient population benefited from decompressive surgery without stabilization. We hypothesize that patients benefit from merely dorsal decompression, which preserves stability when they experience symptomatic spine metastases. We performed a retrospective analysis of electronic patient data from 19 patients, who were treated for symptomatic spine metastases by hemilaminectomy between 2009 and 2017. We evaluated the preoperative and postoperative neurologic functions using the American Spinal Injury Association (ASIA) Impairment Scale. A comparative literature analysis was carried out to assess the Spinal Neoplastic Instability Score, Tokuhashi score, and Tomita score. Nine participants had prostate cancer, 4 had mammary carcinoma, 3 had bronchial carcinoma, and 3 had other cancers. The median preoperative ASIA score was C, postoperatively, the score significantly improved to D (sign test P= 0.002). None of the patients needed stabilization within the follow-up period of up to 56 months. In our patient population, minimal intervention could significantly improve neurologic disorders. This outcome was seen over the whole study period. Even though different scoring systems suggest stabilization, our results show that spinal decompression alone might be indicated as well.

Relationship of joint hypermobility with low Back pain and lumbar spine osteoarthritis

BackgroundChronic low back pain (cLBP) affects millions of Americans and costs billions. Studies suggest a link between cLBP and joint hypermobility.MethodsWe conducted cross-sectional primary analyses of joint hypermobility and cLBP, lumbar spine osteoarthritis (OA), and lumbar facet joint OA (FOA) in 3 large studies—the Generalized Osteoarthritis Study, Genetics of Generalized Osteoarthritis Study, and Johnston County Osteoarthritis Project (total n = 5072). Associations of joint hypermobility and Beighton trunk flexion with cLBP and lumbar OA were estimated using separate adjusted logistic regression models. Adjusted pooled odds ratios (pORs) and 95% confidence intervals (CIs) were then summarized—using random effect univariate, multivariate crude, and adjusted models—and heterogeneity was determined (I2 statistic).ResultsIn univariate models, hypermobility was associated with symptomatic FOA (pOR = 0.64 [95% CI 0.44, 0.93]) but this result was not found in the multivariate models. In multivariate adjusted models, hypermobility was not significantly associated with cLBP and lumbar OA, but trunk flexion was inversely associated with cLBP (pOR = 0.40 [95% 0.26, 0.62]), spine OA (pOR = 0.66 [95% CI 0.50, 0.87]), symptomatic spine OA (pOR = 0.39 [95% CI 0.28, 0.53]), and symptomatic FOA (pOR = 0.53 [95% CI 0.37, 0.77]). Generally, between-study heterogeneity was moderate-high.ConclusionsHypermobility was not associated with cLBP or lumbar OA. The inverse association of trunk flexion with cLBP and lumbar OA may indicate a role for a flexible spine in avoiding or managing these conditions.

Association of Tomato Leaf Curl New Delhi Virus, Betasatellite, and Alphasatellite with Mosaic Disease of Spine Gourd (Momordica dioica Roxb. Willd) in India.

BackgroundSpine gourd (Momordica dioica Roxb. Willd) is one of the important cucurbitaceous crops grown across the world for vegetable and medicinal purposes. Diseases caused by the DNA viruses are becoming the limiting factors for the production of spine gourd reducing its potential yield. For the commercial cultivation of the spine gourd, propagation material used by most of the growers is tuberous roots and stem cuttings, which in turn results in an increased occurrence of the mosaic disease. There is a need for understanding the causal agent; through characterization of which will lead to the designing management strategies for the spine gourd mosaic disease control.ObjectivesCharacterization of a begomovirus and its satellites associated with mosaic disease on spine gourd.Materials and MethodsTotal DNA was extracted from spine gourd samples exhibiting symptoms typical to the begomoviruses infection (mosaic mottling, leaf curl) and was tested by PCR using begomovirus specific primers. Furthermore, the complete genome of begomo viruses (DNA A, DNA B, alpha satellite, and beta satellite) was amplified by rolling circle amplification (RCA) method.ResultsThe full-length sequences of DNA A, DNA B, alpha satellite, and beta satellite isolated from symptomatic spine gourd were determined. The full length genomes (DNA A and DNA B) of the Tomato leaf curl New Delhi Virus (ToLCNDV) infecting spine gourd were compared with the other begomovirus genomes available in the data base. The sequence analysis has revealed that DNA A and DNA B components of the begomovirus infecting spine gourd share 95.4–96.2 and 86.7–91.2% identical sequence (i.e., nucleotide (nt) identity) with that of ToLCNDV infecting potato and cucurbits in the Indian subcontinent isolates reported earlier (available in GenBank), respectively. Further, alpha satellite and beta satellite were also detected in the begomovirus infected spine gourd samples. The recombination analysis of the DNA A, DNA B, beta satellite, and alpha satellite of the begomovirus infecting spine gourd showed the associated begomovirus and satellite DNAs were driven from the different begomoviruses, leading to emergence as a new variant of the begomovirus infecting spine gourd.ConclusionsThe commercial cultivation of the spine gourd by most growers depends on the tuberous roots and stem cutting. The occurrence of begomovirus in spine gourd gives an alarming signal against utilization of such infected plant materials in the crop breeding and improvement programs. Using the clean virus-free vegetative propagation material is considered as one of the most important methods for controlling viral diseases. The study is highly useful for detection of the begomovirus infecting spine gourd in the detection of the virus infection in the clonally propagated planting material.

Top Ten Tips Palliative Care Clinicians Should Know About Spinal Tumors.

Nearly 20% of cancer patients develop symptomatic spine metastases. Metastatic spine tumors are most commonly extradural tumors that grow quickly and often cause persistent pain, weakness, paresthesias, urinary/bowel dysfunction, and/or paralysis. Surgical intervention aims to achieve more effective pain management, preserve/restore neurological function, provide local tumor control, and stabilize the spinal column. The desired result of treatment is ultimately to improve a patient's quality of life. Neurosurgeons employ multiple decision frameworks and grading scales to assess the need and effectiveness of a variety of surgical interventions ranging from minimally to maximally invasive. Likewise, palliative care offers an array of treatment options that allows the best, individualized plan to be determined for a given patient. Therefore, crossfunctional collaboration between palliative care, radiation oncology, medical oncology, and neurosurgery is crucial both in the maximization of available treatment options and optimization of quality of life for patients.

Long-Term Tumor Control with Radiation Therapy for Symptomatic Spine Hemangioma

Data are scarce on long-term results of radiotherapy for symptomatic hemangioma of the spine. The purpose of our study is to report imaging and clinical evidence of tumor control with long-term follow-up after radiotherapy for visible tumor that was not well suited to surgical or interventional radiology treatment. Our study population is all 10 patients treated at our institution between 1968 and 2008 for symptomatic hemangioma of the spine. All patients in our series had substantial pain from visible hemangioma at the time of radiotherapy for which surgical resection or interventional radiology procedures where likely to result in high morbidity. Tumor location in the spine included lumbar in 40%, thoracic in 50%, and cervical in 10% of patients. The mean dose delivered was 47 Gy. Clinical follow-up was defined as no symptoms of recurrent tumor after RT. Imaging follow-up was defined as no increase in tumor size after RT. The mean imaging follow-up was 8.1 years and the mean clinical follow-up was 21.2 years. The crude calculation rate of local tumor control was 90% (9/10). The only patient with recurrence demonstrated tumor progression 30 years after RT. The actuarial rate of tumor control was 100% at 5, 10, 20, and 25 years. There were no grade 3+ treatment toxicities, no evidence of malignant transformation, and no evidence of second tumors in the treatment area. RT for symptomatic hemangioma of the spine provides long-term tumor control without complications. Radiation therapy should be considered in patients for whom surgical resection would result in unacceptable morbidity. Our preferred dose program is 45 Gy at 1.8 Gy per treatment.

Intervertebral disc degeneration induced by long-segment in-situ immobilization: a macro, micro, and nanoscale analysis

BackgroundCervical spine fixation or immobilization has become a routine treatment for spinal fracture, dislocation, subluxation injuries, or spondylosis. The effects of immobilization of intervertebral discs of the cervical spine is unclear. The goal of this study was to evaluate the effects of long-segment in-situ immobilization of intervertebral discs of the caudal vertebra, thereby simulating human cervical spine immobilization.MethodsThirty-five fully grown, male Sprague-Dawley rats were used. Rats were randomly assigned to one of five groups: Group A, which served as controls, and Groups B, C, D, and E, in which the caudal vertebrae were in-situ immobilized using a custom-made external device that fixed four caudal vertebrae (Co7-Co10). After 2 weeks, 4 weeks, 6 weeks, and 8 weeks of in-situ immobilization, the caudal vertebrae were harvested, and the disc height, the T2 signal intensity of the discs, disc morphology, the gene expression of discs, and the structure and the elastic modulus of discs was measured.ResultsThe intervertebral disc height progressively decreased, starting at the 6th week. At week 6 and week 8, disc degeneration was classified as grade III, according to the modified Pfirrmann grading system criteria. Long-segment immobilization altered the gene expression of discs. The nucleus pulposus showed a typical cell cluster phenomenon over time. The annulus fibrosus inner layer began to appear disordered with fissure formation. The elastic modulus of collagen fibrils within the nucleus pulposus was significantly decreased in rats in group E compared to rats in group A (p < 0.05). On the contrary, the elastic modulus within the annulus was significantly increased in rats in group E compared to rats in group A (p < 0.05).ConclusionLong-segment in-situ immobilization caused target disc degeneration, and positively correlated with fixation time. The degeneration was not only associated with changes at the macroscale and microscale, but also indicated changes in collagen fibrils at the nanoscale. Long-segment immobilization of the spine (cervical spine) does not seem to be an innocuous strategy for the treatment of spine-related diseases and may be a predisposing factor in the development of the symptomatic spine.

Cross-cultural adaptation, validity, and reliability of the Persian version of the spine functional index

BackgroundThere are various instruments and methods to evaluate spinal health and functional status. Whole-spine patient reported outcome (PRO) measures, such as the Spine Functional Index (SFI), assess the spine from the cervical to lumbo-sacral sections as a single kinetic chain. The aim of this study was to cross-culturally adapt the SFI for Persian speaking patients (SFI-Pr) and determine the psychometric properties of reliability and validity (convergent and construct) in a Persian patient population.MethodsThe SFI (English) PRO was translated into Persian according to published guidelines. Consecutive symptomatic spine patients (104 female and 120 male aged between 18 and 60) were recruited from three Iranian physiotherapy centers. Test-retest reliability was performed in a sub-sample (n = 31) at baseline and repeated between days 3–7. Convergent validity was determined by calculating the Pearson’s r correlation coefficient between the SFI-Pr and the Persian Roland Morris Questionnaire (RMQ) for back pain patients and the Neck Disability Index (NDI) for neck patients. Internal consistency was assessed using Cronbach’s α. Exploratory Factor Analysis (EFA) used Maximum Likelihood Extraction followed by Confirmatory Factor Analysis (CFA).ResultsHigh levels of internal consistency (α = 0.81, item range = 0.78–0.82) and test-retest reliability (r = 0.96, item range = 0.83–0.98) were obtained. Convergent validity was very good between the SFI and RMQ (r = 0.69) and good between the SFI and NDI (r = 0.57). The EFA from the perspective of parsimony suggests a one-factor solution that explained 26.5% of total variance. The CFA was inconclusive of the one factor structure as the sample size was inadequate. There were no floor or ceiling effects.ConclusionsThe SFI-Pr PRO can be applied as a specific whole-spine status assessment instrument for clinical and research studies in Persian language populations.

OS6-45 Isolated, overlooked, traumatic, symptomatic scapular spine fractures

OS6-45 Isolated, overlooked, traumatic, symptomatic scapular spine fractures

Predictors of survival in patients with surgical spine multiple myeloma metastases

BackgroundMultiple myeloma (MM) is the most common primary malignant tumor of the spine and bone. Spinal metastases are part of the evolution and progression of the MM disease. Therefore, this study aims at investigating prognostic factors associated with overall survival (OS) in patients with symptomatic spine MM metastases. MethodsConsecutive spine surgery procedures were performed in the largest series reported to date and comprising 51 patients with osteolytic vertebral compression fractures resulting from MM, diagnosed by either bone marrow or tumor biopsy. ResultsThe mean age of patients was 61.1 years and mean follow-up was 31.9 months. Through univariate analyses, ISS stage (p < 0.0001), preoperative spine instability (SINS score) (p < 0.03), posterior osteosynthesis fixation (p < 0.002), preoperative adjuvant therapy (p < 0.02), postoperative adjuvant treatment (p < 0.001), bone marrow transplant (p < 0.03) and newly MM diagnosed (p < 0.03) emerged as powerful predictors of survival. Cox multivariate proportional hazard model indicated that only ISS Stage and stabilization surgery such as osteosynthesis were two independent predictive factors for OS [hazard ratio (HR): 0.268, 95% confidence interval (CI) 0.07–0.536; p < 0.006 for the former and HR: 0.184, 95% confidence interval (CI) 0.03–0.89; p < 0.04 for the latter]. ConclusionStabilization surgery combined to ISS staging should be considered as an important prognostic survival factor for patients with symptomatic MM spine metastases.

Quality of Life Analysis and Smoking Correlation in Symptomatic Spine Osteoarthritis: A Nationwide Health Survey Analysis of an Elderly Population with EQ-5D.

ObjectivesTo analyze quality of life in people with symptomatic spine osteoarthritis (OA) using the results of a cross-sectional, nationwide survey.Materials and MethodsThis study used data from the Fifth Korean National Health and Nutrition Examination Survey (KNHANES V-5; 2010–2012). After excluding ineligible subjects, the total number of subjects in the study was 8,963, including 4,091 males and 4,872 females. All participants reported disabilities related to spine OA. Plain radiographs of the spine were taken for all participants.ResultsAge, sex, smoking, drinking, education, and income level were significantly related to spine OA morbidity (P<0.05). OA morbidity was significantly higher in female ex-smokers (OR; 2.94, P<0.05). Quality of life (EQ-5D: L1~5) was significantly compromised in the group with spine OA compared to the group without spine OA (P<0.05). Overall, LQ 1, 2, 3, 4, and 5 domain scores were significantly higher in the group with spine OA (P<0.05). In the group with spine OA, quality of life was reduced on more than three questions for 34.3% of the group (EQ-5D: grade≥2); on two questions, for 18.5% of the group; and on one question, for 11.1% of the group. Mental stress, melancholy, and suicidal thinking were also more common in the group with spine OA (P<0.05). The group with radiographic spine OA but without symptoms did not have compromised EQ-5D scores, whereas the group with radiographic OA and symptoms showed a significantly reduced quality of life.ConclusionsQuality of life was significantly reduced in the group with symptomatic spine OA in a large cross-sectional analysis. Physicians should consider quality of life in the treatment of patients with spine OA