Time Of Spinal Surgery Research Articles

A 10-Year Retrospective Review on the Use of Prophylactic Spinal Reconstruction in Spinal Surgery Involving High-Risk Patients.

Spinal surgeries are being offered to a broader patient population who are both medically and surgically complex. History of prior spinal surgery, advanced age, and presence of comorbidities, such as obesity, malnutrition, steroid use, and tobacco use, are risk factors for postoperative complications. Prophylactic spinal reconstruction at the time of spinal surgery has been shown to have improved outcomes and decreased wound complications; however, outcomes focusing specifically on complex patients with a history of previous spinal surgery (or surgeries) have not been well described. This is a retrospective study performed at the University of Maryland Medical Center (Baltimore, MD) of high-risk patients who underwent complex spinal surgery with prophylactic spinal reconstruction from 2011 to 2022. One hundred forty-three consecutive surgeries from 136 patients were included in the study. Patients younger than 17 years or who had an incomplete medical record were excluded. Most patients were female (63.6%) versus male (31.5%). The average American Society of Anesthesiologists score was 3. All but 6 patients (11%) had a history of at least 1 spinal surgery, with nearly half of patients having had between 2 and 5 spinal surgeries. Reconstruction was performed with paraspinous flaps in most cases (n = 133 [93%]). The overall complication rate was 10.5%, with surgical site infection being the most common complication. Seventeen patients (12.5%) underwent reoperation within 90 days of initial surgery. Average length of follow-up was 4.18 months (range, 0.03-40.53 months). In appropriately selected patients, prophylactic spinal reconstruction offers improved outcomes with decreased wound complications compared with salvage. For large defects, paraspinous flaps are recommended over other reconstructive options. Prolonged drain placement is felt to be protective against complications.

Timing of Spinal Surgery in Polytrauma: The Relevance of Injury Severity, Injury Level and Associated Injuries.

Retrospective database analysis. Polytraumatized patients with spinal injuries require tailor-made treatment plans. Severity of both spinal and concomitant injuries determine timing of spinal surgery. Aim of this study was to evaluate the role of spinal injury localization, severity and concurrent injury patterns on timing of surgery and subsequent outcome. The TraumaRegister DGU® was utilized and patients, aged ≥16years, with an Injury Severity Score (ISS) ≥16 and diagnosed with relevant spinal injuries (abbreviated injury scale, AIS ≥ 3) were selected. Concurrent spinal and non-spinal injuries were analysed and the relation between injury severity, concurrent injury patterns and timing of spinal surgery was determined. 12.596 patients with a mean age of 50.8years were included. 7.2% of patients had relevant multisegmental spinal injuries. Furthermore, 50% of patients with spine injuries AIS ≥3 had a more severe non-spinal injury to another body part. ICU and hospital stay were superior in patients treated within 48hrs for lumbar and thoracic spinal injuries. In cervical injuries early intervention (<48hrs) was associated with increased mortality rates (9.7 vs 6.3%). The current multicentre study demonstrates that polytrauma patients frequently sustain multiple spinal injuries, and those with an index spine injury may therefore benefit from standardized whole-spine imaging. Moreover, timing of surgical spinal surgery and outcome appear to depend on the severity of concomitant injuries and spinal injury localization. Future prospective studies are needed to identify trauma characteristics that are associated with improved outcome upon early or late spinal surgery.

Spinal Surgery after Bilateral Subthalamic Stimulation for Patients with Parkinson's Disease: A Retrospective Outcome Analysis of Pain and Functional Control.

Parkinson’s disease (PD) patients often suffer from spinal diseases requiring surgeries, although the risk of complications is high. There are few reports on outcomes after spinal surgery for PD patients with deep brain stimulation (DBS). The objective of this study was to explore the data on spinal surgery for PD patients with precedent DBS. We evaluated 24 consecutive PD patients with 28 spinal surgeries from 2007 to 2017 who received at least a 2-year follow-up. The characteristics and outcomes of PD patients after spinal surgery were compared to those of 156 non-PD patients with degenerative spinal diseases treated in 2013–2017. Then, the characteristics, outcomes, and spinal alignment of PD patients receiving DBS were analyzed in degenerative spinal/lumbar diseases. The mean age at the time of spinal surgery was 68 years. The Hoehn and Yahr score regarding PD was stage 1 for 8 patients, stage 2 for 2 patients, stage 3 for 8 patients, stage 4 for 10 patients, and stage 5 for 0 patient. The median preoperative L-DOPA equivalent daily dose was 410 mg. Thirteen patients (46%) received precedent subthalamic nucleus (STN) DBS. Lumbar lesions with pain were common, and operation and anesthesia times were long in PD patients. Pain and functional improvement of PD patients persisted for 2 years after surgery with a higher complication rate than for non-PD patients. PD patients with STN DBS maintained better lumbar lordosis for 2 years after spinal surgery. STN DBS significantly maintained spinal alignment with subsequent pain and functional amelioration 2 years after surgery. The outcomes of spinal surgery for PD patients might be favorably affected by thorough treatment for PD including DBS.

Soft-Tissue Reconstruction of Large Spinal Defects: A 12-Year Institutional Experience.

Spinal resections can lead to defects requiring soft-tissue reconstruction. The purpose of this study was to review the authors' institutional experience with reconstruction of spinal defects and identify risk factors predictive of wound complications, focusing on timing of reconstruction with ablative surgery. The authors retrospectively reviewed patients who underwent spinal resection and required soft-tissue reconstruction from 2002 to 2014. Logistic regression was performed to identify risk factors for complications. Of 289 reconstructions performed in 259 patients, 64 cases (22.1 percent) had major wound complications requiring reoperation. Lumbosacral defects were the most common location (43.6 percent) and paraspinous muscle flaps were the preferred reconstructive method used for all defect regions. A total of 224 reconstructions (77.5 percent) were performed immediately at the time of spinal surgery, and 65 (22.5 percent) were performed in delayed fashion as a result of wound complications from previous spinal surgery. Patients undergoing immediate reconstruction had significantly lower rates of instrumentation removal (0.9 percent versus 4.6 percent; p = 0.043), unplanned reoperations (0.5 versus 1.3; p < 0.001), and mortality (0.9 percent versus 9.2 percent; p < 0.001) compared with those undergoing delayed reconstruction. On logistic regression analysis, presence of instrumentation (OR, 3.2; p = 0.012), requirement for a free flap (OR, 9.0; p = 0.016), and spinal cord exposure (OR, 2.6; p = 0.036) were associated with increased odds of a major wound complication. Spinal resections carry significant surgical-site morbidity, and selection of high-risk patients for immediate reconstruction with locoregional muscle flaps may be beneficial for improving wound-related outcomes. Therapeutic, III.

Factors associated with improved survival following surgical treatment for metastatic prostate cancer in the spine: retrospective analysis of 29 patients in a single center.

BackgroundProstate cancer (PCa) is very common and frequently metastasizes to the spine. However, PCa spinal metastases were rarely reported in the literature. In this study, the outcome of therapies and prognostic factors affecting surgical outcomes for patients with PCa spinal metastases are discussed to select the best candidates for aggressive surgical resection.MethodsAll patients affected by the spinal metastatic PCa surgically treated at our spine tumor center were reviewed. Overall survival was analyzed from the time of spinal surgery. A univariate survival analysis and a multivariate Cox proportional hazard analysis to identify independent prognostic factors were carried out. The survival rate was estimated by the Kaplan-Meier method, and differences were analyzed by the log-rank test. Factors with P values of 0.1 or less were subjected to multivariate analysis for survival rate by multivariate Cox proportional hazard analysis.ResultsA total of 31 consecutive patients were identified. Of these, 29 underwent surgical resection. The median survival time of all patients after their spinal surgery was 44.0 months. Visceral metastases, revised Tokuhashi scores (0–8/9–11/12–15), Tomita scores (7–10/2–6), hormone status, and bisphosphonate treatment were suggested as the potential prognostic factors through univariate analysis. As they were submitted to the multivariate Cox regression model, visceral metastases and Tomita score were found as independent prognostic factors.ConclusionsPatients without visceral metastases and a Tomita score no more than 6 are favorable prognostic factors for PCa metastases in the mobile spine.

The Use of Secondary Prognostic Parameters when Malignancy of Undefined Primary Origin is Present in Spinal Metastases

Introduction Accurate prognostication is not feasible when the primary malignancy is unknown. Patients who harbor spinal metastases with malignancy of undefined primary origin are common in the clinical scenario of installed paraplegia within 24 hours or rapid progressive paraparesis. Acute spinal nervous tissue compression is an indication for urgent surgery and should be performed within 24 hours of hospitalization. In this urgent clinical situation, time-consuming neoplastic disease staging may not be feasible. An estimated 3-month post-operative survival period seems reasonable for the decision-making process regarding whether surgery should be performed. When the primary malignancy site is unknown, secondary parameters are used to estimate patient survival. Special patient care dependency, spinal cord tumor compression, walking impairment, urgent surgery, and malignancy of undefined primary origin can be used to estimate survival and can act as secondary prognostic parameters of survival. The objective of this study is to identify pre-operative prognostic parameters for survival in patients with spinal metastasis when malignancy of undefined primary origin is present. Material and Methods This study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. Inclusion criteria: Knowledge of the post-operative survival period. Five pre-operative prognostic parameters for patient survival where identified: Special care dependency (Karnofsky Performance Score ≧30 points); Spinal cord tumor compression (MRI/TAC spinal imaging); Walking impairment ( ASIA Scale A &amp; B); Urgent surgery; Malignancy of undefined primary origin. Statistical analysis compared patients with the selected five prognostic parameters for survival to those with one to four of these prognostic parameters. The Kaplan–Meier method was used to estimate the post-operative survival and the log-rank test was used for statistical inference. Results A total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (standard deviation 19.09). Malignancy of undefined primary origin was present in 36 (69.23%) of the patients in the preoperative period. The overall median survival after surgery was 70 days (95% CI: 49.97–90.02) and post-operative mortality occurred within 6 months in 38 (73.07%) patients. The median post-operative survival for the 16 (30.77%) patients harboring the selected five prognostic parameters to estimate survival was 22 days (95% CI: 4.36–39.64) and for the other 36 (69.23%) patients with one to four of the prognostic parameters, 72 days (95% CI: 57.30–86.70). The mean post-operative survival for the same 16 (30.77%) patients harboring the selected five prognostic parameters to estimate survival was 109.75 days (95% CI: 107.49–251.27) and for the other same 36 (69.23%) patients with one to four of the prognostic parameters, 210.33 days (95% CI: 118.46–302.20). Statistical inference for the five analyzed prognostic parameters was p-value = 0.123 Conclusion Patient special care dependency, spinal cord tumor compression, walking impairment, urgent surgery and malignancy of undefined primary origin are useful as secondary prognostic parameters for patient survival. A 2- to 3-month post-operative survival period justified surgical treatment in this study.

The Prognostic Factor of Malignancy of Undefined Primary Origin in Spinal Metastases

Introduction Malignancy of undefined primary origin is metastatic malignancy identified on the basis of a limited number of tests, without an obvious primary site, before comprehensive investigation.2 Patients who harbor spinal epidural neoplastic metastases with malignancy of undefined primary origin are common in the clinical scenario of installed paraplegia within 24 hours or rapid progressive paraparesis. Acute spinal nervous tissue compression is an indication for urgent surgery and should be performed within 24 hours of hospitalization. In this urgent clinical situation, time-consuming neoplastic disease staging may not be feasible. An estimated 3-month postoperative survival period seems reasonable for the decision-making process regarding whether surgery should be performed. The physician may reason that if the knowledge of the primary tumor site is not a prognostic factor for survival in preoperative urgent surgery for spinal epidural neoplastic metastases, then surgery must not be postponed. The objective of this study is to compare the postoperative survival between patients with defined and undefined malignancy of primary origin as a prognostic factor for survival in spinal metastases. Material and Methods This study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. The inclusion criteria were as follows: known postoperative survival period, a Karnofsky performance score equal to or greater than 30 points, and a postoperative neoplastic metastasis histological type. The Kaplan–Meier method was used to estimate the postoperative survival and the log-rank test was used for statistical inference. Results A total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (standard deviation 19.09). The median survival after surgery was 70 days (95% CI: 49.97–90.02) and postoperative mortality occurred within 6 months in 38 patients (73.07%). The primary neoplasm site and histological type were unknown in 36 (69.23%) of the patients in the preoperative period. The following primary tumor types were identified after the surgery: myeloma (8 patients), lung carcinoma (6), sarcoma (5), prostate carcinoma (5), lymphoma (4), undifferentiated carcinoma (4), thyroid carcinoma (1), pineal germinoma (1), gastric adenoma (1), and kidney blastoma (1). Cancer type was the strongest overall survival indicator in this study ( p = 0.023). The median postoperative survival for the 16 patients (30.77%) with known preoperative primary tumors was 59 days (95% CI: 11.96–106.04) and it was 72 days (95% CI: 51.45–92.54) for the 36 patients (69.23%) with unknown tumors. The statistical inference was p = 0.719 and statistically insignificant for postoperative survival between the known and unknown primary tumor site. The median postoperative survival in patients with elective surgery was 76 days (95% CI: 53.571–98.429) and for urgent surgery was 45 days (95% CI: 3.553–86.447). The statistical inference was p = 0.124 for postoperative survival between the elective and urgent surgery patients. Conclusion Undefined malignancy of primary origin is not a prognostic factor for survival in patients who harbor spinal epidural neoplastic metastases when compared with those with a defined malignancy of primary origin in this research study. References Daniel JW. Survival prognostic parameters in patients with spinal column epidural metastatic neoplasms [PhD thesis]. São Paulo, SP, Brazil: Santa Casa de São Paulo, Faculty of Medical Sciences; 2013 National Institute for Health and Clinical Excellence. 2010. Metastatic malignant disease of unknown primary origin. London: NICE clinical guideline. Available at: https://www.nice.org.uk/search?q=Metastatic+malignant+disease+of+unknown+primary+origin. Accessed September 20, 2014

Prognostic parameters and spinal metastases: a research study.

ObjectTo identify pre-operative prognostic parameters for survival in patients with spinal epidural neoplastic metastasis when the primary tumour is unknown.MethodsThis study was a retrospective chart review of patients who underwent surgery for spinal epidural neoplastic metastases between February 1997 and January 2011. The inclusion criteria were as follows: known post-operative survival period, a Karnofsky Performance Score equal to or greater than 30 points and a post-operative neoplastic metastasis histological type. The Kaplan-Meier method was used to estimate post-operative survival, and the Log-Rank test was used for statistical inference.ResultsA total of 52 patients who underwent 52 surgical procedures were identified. The mean age at the time of spinal surgery was 53.92 years (std. deviation, 19.09). The median survival after surgery was 70 days (95% CI 49.97–90.02), and post-operative mortality occurred within 6 months in 38 (73.07%) patients. Lung cancer, prostate cancer, myeloma and lymphoma, the 4 most common primary tumour types, affected 32 (61.53%) patients. The three identified prognostic parameters were the following: pre-operative walking incapacity (American Spinal Injury Association, A and B), present in 86.53% of the patients (p-value = 0.107); special care dependency (Karnofsky Performance Score, 10–40 points), present in 90.38% of the patients (p-value = 0.322); and vertebral epidural neoplastic metastases that were in contact with the thecal sac (Weinstein-Boriani-Biagini, sector D), present in 94.23% of the patients (p-value = 0.643). When the three secondary prognostic parameters were combined, the mean post-operative survival was 45 days; when at least one was present, the survival was 82 days (p-value = 0.175).ConclusionsWalking incapacity, special care dependency and contact between the neoplastic metastases and the thecal sac can help determine the ultimate survival of this patient population and, potentially, which patients would benefit from surgery versus palliation alone. A 2- to 3-month post-operative survival period justified surgical treatment.

Spinal surgery in the univentricular heart – is it viable?

The management of patients with Fontan physiology who undergo scoliosis surgery is difficult. The purpose of this article was to describe our experience in the management of patients with Fontan circulation undergoing spinal surgery for correction of scoliosis. This was a retrospective study including patients with Fontan physiology who underwent spinal orthopaedic surgery. Anaesthetic management, post-operative complications, paediatric intensive care unit and total hospital stay, and the need for blood transfusions were analysed. We identified eight children with Fontan physiology who had undergone spinal surgery from 2000 to 2010. All patients were receiving cardiac medications at the time of spinal surgery. The mean age at surgery was 14.8 years (range 12-21). In all, three patients needed inotropic support with dopamine (3, 5, and 8 μg/kg/min), which was started during surgery. During the immediate post-operative period, one patient died because of hypovolaemic shock caused by massive bleeding and dysrythmia. Mean blood loss during the post-operative period was 22.2 cc/kg (7.8-44.6). Surgical drainages were maintained for a mean time of 3 days (range 1-7). The mean hospital stay was 9.2 days (range 6-19). Pleural effusions developed in two patients. On follow-up, one patient presented with thoracic pseudarthrosis and another with a serohaematoma of the surgical wound. Spinal surgery in patients with Fontan circulation is a high-risk operation. These patients must be managed by a specialised team.

Outcome after surgery for metastatic spinal cord compression in 54 patients with prostate cancer

Background and purpose The criteria for selecting patients who may benefit from surgery of spinal cord compression in metastatic prostate cancer are poorly defined. We therefore studied patients operated for metastatic spinal cord compression in order to evaluate outcome of surgery and to find predictors of survival.Patients and methods We reviewed the records of 54 consecutive patients with metastatic prostate cancer who were operated for spinal cord compression at Umeå University Hospital. The indication for surgery was neurological deficit due to spinal cord compression. 41 patients had hormone-refractory cancer and 13 patients had previously untreated, hormone-naïve prostate cancer. 29 patients were operated with posterior decompression only, and in 25 patients posterior decompression and stabilization was performed.Results Preoperatively, 6/54 of patients were able to walk. 1 month after surgery, 33 patients were walking, 15 were non-ambulatory, and 6 had died. Mortality rate was 11% at 1 month, 41% at 6 months, and 59% at 1 year. In the hormone-naïve group, 8/13 patients were still alive with a median postoperative follow-up of 26 months. In the hormone-refractory group, median survival was 5 months. Patients with hormone-refractory disease and Karnofsky performance status (KPS) of ≤ 60% had median survival of 2.5 months, whereas those with KPS of 70% and KPS of ≥ 80% had a median survival of 7 months and 18 months, respectively (p < 0.001). Visceral metastases were present in 12/41 patients with hormone-refractory tumor at the time of spinal surgery, and their median survival was 4 months—as compared to 10 months in patients without visceral metastases (p = 0.003). Complications within 30 days of surgery occurred in 19/54 patients.Interpretation Our results indicate that patients with hormone-naive disease, and those with hormone-refractory disease with good performance status and lacking visceral metastases, may be helped by surgery for metastatic spinal cord compression.