Tag: Spine

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Aneurysmal bone cysts of the spine: treatment options and considerations

ABC

J Neurooncol (2014) 120:171–178

Aneurysmal bone cysts (ABCs) are benign bone lesions with annual incidences ranging from 1.4 to 3.2 cases per million people. Approximately, 10–30 % of ABCs are found in the spine. Such lesions are traditionally treated with curettage or other intralesional techniques.

Because ABCs can be locally aggressive, intralesional resection can be incomplete and result in recurrence. This has led to increased use of novel techniques, including selective arterial embolization (SAE).

This study aims to: (1) compare outcomes based on extent of surgical resection, and (2) compare the efficacy of SAE versus surgical resection.

Clinical data pertaining to 71 cases of spinal ABCs were ambispectively collected from nine institutions in Europe, North America, and Australia. Twenty-two spinal ABCs were treated with surgery, 32 received preoperative embolization and surgery, and 17 were treated with SAE.

Most tumors were classified as Enneking stage 2 (n = 29, 41 %) and stage 3 (n = 29, 41 %). Local recurrence and survival were investigated and a significant difference was not observed between treatment groups. However, all three local recurrences occurred following surgical resection. Surgical resection was further categorized based on Enneking appropriateness. Recurrences only occurred following intralesional Enneking inappropriate (EI) resections (P = 0.10), a classification that characterized 47 % of all surgical resections. Furthermore, 56 % of intralesional resections were EI, compared to only 10 % of en bloc resections (P = 0.01). Although SAE treatment did not result in any local recurrences, 35 % involved more than five embolization procedures.

Spinal ABCs can be effectively treated with intralesional resection, en bloc resection, or SAE. Preoperative embolization should be considered before intralesional resection to limit intraoperative bleeding. Treatment plans must be guided by lesion characteristics and clinical presentation.

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Surgical treatment of pathological loss of lumbar lordosis (flatback)

Flatback

J Neurosurg Spine 21:160–170, 2014

Increased sagittal vertical axis (SVA) correlates strongly with pain and disability for adults with spinal deformity. A subset of patients with sagittal spinopelvic malalignment (SSM) have flatback deformity (pelvic incidence–lumbar lordosis [PI-LL] mismatch > 10°) but remain sagittally compensated with normal SVA. Few data exist for SSM patients with flatback deformity and normal SVA. The authors’ objective was to compare baseline disability and treatment outcomes for patients with compensated (SVA < 5 cm and PI-LL mismatch > 10°) and decompensated (SVA > 5 cm) SSM.

Methods. The study was a multicenter, prospective analysis of adults with spinal deformity who consecutively underwent surgical treatment for SSM. Inclusion criteria included age older than 18 years, presence of adult spinal deformity with SSM, plan for surgical treatment, and minimum 1-year follow-up data. Patients with SSM were divided into 2 groups: those with compensated SSM (SVA < 5 cm and PI-LL mismatch > 10°) and those with decompensated SSM (SVA ≥ 5 cm). Baseline and 1-year follow-up radiographic and health-related quality of life (HRQOL) outcomes included Oswestry Disability Index, Short Form–36 scores, and Scoliosis Research Society–22 scores. Percentages of patients achieving minimal clinically important difference (MCID) were also assessed.

Results. A total of 125 patients (27 compensated and 98 decompensated) met inclusion criteria. Compared with patients in the compensated group, patients in the decompensated group were older (62.9 vs 55.1 years; p = 0.004) and had less scoliosis (43° vs 54°; p = 0.002), greater SVA (12.0 cm vs 1.7 cm; p < 0.001), greater PI-LL mismatch (26° vs 20°; p = 0.013), and poorer HRQOL scores (Oswestry Disability Index, Short Form-36 physical component score, Scoliosis Research Society-22 total; p ≤ 0.016). Although these baseline HRQOL differences between the groups reached statistical significance, only the mean difference in Short Form–36 physical component score reached threshold for MCID. Compared with baseline assessment, at 1 year after surgery improvement was noted for patients in both groups for mean SVA (compensated –1.1 cm, decompensated +4.8 cm; p ≤ 0.009), mean PI-LL mismatch (compensated 6°, decompensated 5°; p < 0.001), and all HRQOL measures assessed (p ≤ 0.005). No significant differences were found between the compensated and decompensated groups in the magnitude of HRQOL score improvement or in the percentages of patients achieving MCID for each of the outcome measures assessed.

Conclusions. Decompensated SSM patients with elevated SVA experience significant disability; however, the amount of disability in compensated SSM patients with flatback deformity caused by PI-LL mismatch but normal SVA is underappreciated. Surgical correction of SSM demonstrated similar radiographic and HRQOL score improvements for patients in both groups. Evaluation of SSM should extend beyond measuring SVA. Among patients with concordant pain and disability, PI-LL mismatch must be evaluated for SSM patients and can be considered a primary indication for surgery.

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Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma

Neurosurg Focus 37 (1):E11, 2014

Thoracolumbar and lumbar trauma account for the majority of traumatic spinal injuries. The mainstay of current treatments is still nonoperative therapy with bracing. Classic treatment algorithms reserved absolute surgical intervention for spinal trauma patients with neurological compromise or instability. Relative indications included incapacitating pain and obesity/body habitus making brace therapy ineffective.

In the past decade, minimally invasive surgical (MIS) techniques for spine surgery have been increasingly used for degenerative conditions. These same minimally invasive techniques have seen increased use in trauma patients. The goal of minimally invasive surgery is to decrease surgical morbidity through decreased soft-tissue dissection while providing the same structural stability afforded by classic open techniques.

These minimally invasive techniques involve percutaneous posterior pedicle fixation, vertebral body augmentation, and utilization of endoscopic and thoracoscopic techniques.

While MIS techniques are somewhat in their infancy, an increasing number of studies are reporting good clinical and radiographic outcomes with these MIS techniques. However, the literature is still lacking high-quality evidence comparing these newer techniques to classic open treatments. This article reviews the relevant literature regarding minimally invasive spine surgery in the treatment of thoracolumbar and lumbar trauma.

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Cost-effectiveness analysis in minimally invasive spine surgery

Cost-effectiveness analysis in MISS

Neurosurg Focus 36 (6):E4, 2014

Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs.

Methods. A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded.

Results. Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%—all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10–392.5 ml) than in an open approach (range 55–535.5 ml).

Conclusions. There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

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Traumatic injuries to the craniovertebral junction: a review of rare events

Traumatic injuries CVJ

Neurosurg Rev (2014) 37:203–216

The craniovertebral junction is a specific region of the spine with unique anatomical and biomechanical properties that yields a wide variety of injury patterns.

Junctional traumatic fractures and/or dislocations are widely reported in clinical practice, but we could identify only a subgroup of upper cervical spine traumatic injuries with very few cases reported in the literature, and for this reason may be considered rare.

In some of these cases, the absence of spinal biomechanical instability, in association with moderate clinical symptoms (neck stiffness and pain) and the difficulty in fracture identification through standard cervical radiographs, leads to a high percentage of missed injuries.

In other cases, traumatic events have been commonly described only in autopsy series due to the high degree of spinal biomechanical instability.

Herein, we have summarized all the relevant literature concerning this issue and also included our cases, with the aim of emphasizing prompt diagnosis and correct management.

We provide a guide for correctly identifying “rare” craniovertebral junction traumatic injuries.

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A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction

Standardized nomenclature cervical osteotomies

J Neurosurg Spine 19:269–278, 2013

Cervical spine osteotomies are powerful techniques to correct rigid cervical spine deformity. Many variations exist, however, and there is no current standardized system with which to describe and classify cervical osteotomies. This complicates the ability to compare outcomes across procedures and studies. The authors’ objective was to establish a universal nomenclature for cervical spine osteotomies to provide a common language among spine surgeons.

METHODS

A proposed nomenclature with 7 anatomical grades of increasing extent of bone/soft tissue resection and destabilization was designed. The highest grade of resection is termed the major osteotomy, and an approach modifier is used to denote the surgical approach(es), including anterior (A), posterior (P), anterior-posterior (AP), posterior-anterior (PA), anterior-posterior-anterior (APA), and posterior-anterior-posterior (PAP). For cases in which multiple grades of osteotomies were performed, the highest grade is termed the major osteotomy, and lower-grade osteotomies are termed minor osteotomies. The nomenclature was evaluated by 11 reviewers through 25 different radiographic clinical cases. The review was performed twice, separated by a minimum 1-week interval. Reliability was assessed using Fleiss kappa coefficients.

RESULTS

The average intrarater reliability was classified as “almost perfect agreement” for the major osteotomy (0.89 [range 0.60–1.00]) and approach modifier (0.99 [0.95–1.00]); it was classified as “moderate agreement” for the minor osteotomy (0.73 [range 0.41–1.00]). The average interrater reliability for the 2 readings was the following: major osteotomy, 0.87 (“almost perfect agreement”); approach modifier, 0.99 (“almost perfect agreement”); and minor osteotomy, 0.55 (“moderate agreement”). Analysis of only major osteotomy plus approach modifier yielded a classification that was “almost perfect” with an average intrarater reliability of 0.90 (0.63–1.00) and an interrater reliability of 0.88 and 0.86 for the two reviews.

CONCLUSIONS

The proposed cervical spine osteotomy nomenclature provides the surgeon with a simple, standard description of the various cervical osteotomies. The reliability analysis demonstrated that this system is consistent and directly applicable. Future work will evaluate the relationship between this system and health-related quality of life metrics.

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Pathology of Spinal Ependymomas

Pathology of Spinal Ependymomas

Neurosurgery 73:247–255, 2013

Ependymomas constitute approximately 40% of primary intraspinal tumors. Current World Health Organization (WHO) grading may not correlate with observed progression-free survival (PFS).

OBJECTIVE: This retrospective study of prospectively collected data examines whether PFS is influenced by the histological grade or by the extent of resection. It also analyzes the usage and effectiveness of postoperative adjuvant radiotherapy.

METHODS: We reviewed 134 consecutive patients with ependymomas of all grades. Pathology slides were re-reviewed and the histological grades were confirmed by a single neuropathologist. Postoperative residual or recurrence was evaluated with follow-up magnetic resonance imaging.

RESULTS: There were 85 male and 49 female patients, ranging from 10 to 79 (median 41) years of age. Thirty patients had WHO grade I tumors, 101 had grade II tumors, and 3 had grade III tumors. Kaplan-Meier analysis of PFS demonstrated a mean duration of 6 years for grade I, 14.9 years for grade II, and 3.7 years for grade III (P , .001). In grade II ependymomas, mean PFS was 11.2 years with subtotal resection and 17.8 years with gross total resection (P, .01). PFS of patients who underwent subtotal resection was not significantly changed by adjuvant radiotherapy (P , .36).

CONCLUSION: Patients with grade II ependymoma have significantly longer PFS than patients with grade I ependymoma. The extent of resection did not affect PFS in grade I ependymoma but it did in grade II. Contrary to its higher grade, WHO grade II ependymoma carries a better prognosis than WHO grade I ependymoma.

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Axial Spondylectomy and Circumferential Reconstruction via a Posterior Approach

Axial spondylectomy

Neurosurgery 72:300–309, 2013

Spinal metastases of the second cervical vertebra are a subset of tumors that are particularly difficult to address surgically. Previously described techniques require highly morbid circumferential dissection posterior to the pharynx for resection and reconstruction.

OBJECTIVE: To perform a biomechanical analysis of instrumented reconstruction configurations used after axial spondylectomy and to demonstrate safe use of a novel construct in a patient case report.

METHODS: Several different published and novel reconstruction configurations were inserted into 7 occipitocervical spines that underwent axial spondylectomy. A biomechanical analysis of the stiffness of the constructs in flexion and extension, lateral bending, and rotation was performed. A patient then underwent a posterior-only approach for axial spondylectomy and circumferential reconstruction.

RESULTS: Biomechanical analysis of different constructs demonstrated that anterior column reconstruction with bilateral cages spanning the C1 lateral mass to the C3 facet in combination with occipitocervical instrumentation was superior in flexion-extension and equivalent in lateral bending and rotation to currently used constructs. The patient in whom this construct was placed via a posterior-only approach for axial spondylectomy and instrumentation remained at neurological baseline and demonstrated no recurrence of local disease or failure of instrumentation to date.

CONCLUSION: When C1 lateral mass to C3 facet bilateral cage plus occipitocervical instrumentation is compared with existing anterior and posterior constructs, this novel reconstruction is biomechanically equivalent if not superior in performance. In a patient, the posterior-only approach for C2 spondylectomy with the novel reconstruction was safe and durable and avoided the morbidity of the anterior approach.

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Combined “Hybrid” Open and Minimally Invasive Surgical Correction of Adult Thoracolumbar Scoliosis: A Retrospective Cohort Study

00006123-201302000-00011

Neurosurgery 72:151–159, 2013

Surgery for scoliosis requires extensive exposure, resulting in significant tissue injury and longer recovery times. To minimize morbidity in scoliosis surgery, several studies have shown successful application of a combination of minimally invasive techniques; however, the extent of scoliosis treated has been modest.

OBJECTIVE: To achieve some of the benefits of minimally invasive surgery and yet treat curves of greater degree, we have used a combined approach, incorporating both open and minimally invasive techniques.

METHODS: We analyzed a prospectively acquired database in addition to reviewing electronic records of patients undergoing hybrid surgery for thoracolumbar scoliosis. Nine patients were identified. The minimally invasive portion involved the lumbar region in all cases. Pain was assessed by the visual analog scale and disability was measured by the Oswestry Disability Index.

RESULTS: Mean preoperative scoliosis was 47.8 degrees, which was corrected to a mean 15.2 degrees. An average of 7.8 spinal levels was treated. Estimated blood loss averaged 1094.4 mL, and length of hospital stay averaged 7.2 days. Acute complications occurred in 2 patients. Longer term complications occurred in 2 patients, consisting of adjacent segment disease. The mean improvement in the visual analog scale score was 3.7 and the mean improvement on the Oswestry Disability Index was 30.5. Average follow-up was 29.2 months.

CONCLUSION: The hybrid approach for the treatment of scoliosis results in acceptable radiographic and clinical outcomes. Complications did not appear increased compared with those expected with scoliosis surgery. Although decreased adjacent tissue injury was achieved with the minimally invasive component of the procedure, a larger comparative study is required to determine magnitude of this benefit.

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Incidental durotomy after spinal surgery: a prospective study in an academic institution

J Neurosurg Spine 17:30–36, 2012

Incidental durotomies (IDs) are an unfortunate but anticipated potential complication of spinal surgery. The authors surveyed the frequency of IDs for a single spine surgeon and analyzed the major risk factors as well as the impact on long-term patient outcomes.

Methods. The authors conducted a prospective review of elective spinal surgeries performed over a 15-year period. Any surgery involving peripheral nerve only, intradural procedures, or dural tears due to trauma were excluded from analysis. The incidence of ID was categorized by surgery type including primary surgery, revision surgery, and so forth. Incidence of ID was also examined in the context of years of physician experience and training. Furthermore, the incidence and types of sequelae were examined in patients with an ID.

Results. Among 3000 elective spinal surgery cases, 3.5% (104) had an ID. The incidence of ID during minimally invasive procedures (3.3%) was similar, but no patients experienced long-term sequelae. The incidence of ID during revision surgery (6.5%) was higher. There was a marked difference in incidence between cervical (1.3%) and thoracolumbar (5.1%) cases. The incidence was lower for cases involving instrumentation (2.4%). When physician training was examined, residents were responsible for 49% of all IDs, whereas fellows were responsible for 26% and the attending for 25%. Among all of the cases that involved an ID, 7.7% of patients went on to experience a neurological deficit as compared with 1.5% of those without an ID. The overall failure rate of dural repair was 6.9%, and failure was almost 3 times higher (13%) in revision surgery as compared with a primary procedure (5%).

Conclusions. The authors established a reliable baseline incidence for durotomy after spine surgery: 3.5%. They also identified risk factors that can increase the likelihood of a durotomy, including location of the spinal procedure, type of procedure performed, and the implementation of a new procedure. The years of physician training or resident experience did not appear to be a major risk for ID.

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Role of Cancer Stem Cells in Spine Tumors

Neurosurgery 71:117–125, 2012 DOI: 10.1227/NEU.0b013e3182532e71

The management of spinal column tumors continues to be a challenge for clinicians. The mechanisms of tumor recurrence after surgical intervention as well as resistance to radiation and chemotherapy continue to be elucidated. Furthermore, the pathophysiology of metastatic spread remains an area of active investigation.

There is a growing body of evidence pointing to the existence of a subset of tumor cells with high tumorigenic potential in many spine cancers that exhibit characteristics similar to those of stem cells. The ability to self-renew and differentiate into multiple lineages is the hallmark of stem cells, and tumor cells that exhibit these characteristics have been described as cancer stem cells (CSCs).

The mechanisms that allow nonmalignant stem cells to promote normal developmental programming by way of enhanced proliferation, promotion of angiogenesis, and increased motility may be used by CSCs to fuel carcinogenesis.

The purpose of this review is to discuss what is known about the role of CSCs in tumors of the osseous spine. First, this article reviews the fundamental concepts critical to understanding the role of CSCs with respect to chemoresistance, radioresistance, and metastatic disease. This discussion is followed by a review of what is known about the role of CSCs in the most common primary tumors of the osseous spine.

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Results and complications after 2-level axial lumbar interbody fusion with a minimum 2-year follow-up

J Neurosurg: Spine / July 17, 2012. DOI: 10.3171/2012.6.SPINE11915

Axial lumbar interbody fusion (AxiaLIF) is a minimally invasive presacral surgical technique that damages neither the anulus fibrosus nor the anterior or posterior longitudinal ligaments. The technique was initially designed and used for L5–S1 interbody fusions and recently was extended to 2-level fusions (L4–5 and L5–S1). Until now, only biomechanical and radiological studies have discussed the feasibility of this new indication, and no clinical study has been published. The purpose of this article is to report results and complications associated with 2-level presacral AxiaLIF with a minimum of 24 months of follow-up.

METHODS
In this prospective, nonrandomized, single-center study, 27 patients underwent presacral AxiaLIF surgery at the L4–5 and L5–S1 levels. Clinical outcomes were assessed using the visual analog scale for back and leg symptoms and the Oswestry Disability Index. Radiographic parameters, such as disc height, segmental lordosis, and bone fusion, were analyzed using radiographs and CT scans. Complications and revision surgeries were recorded as needed. The minimum follow-up was 24 months (up to 72 months).

RESULTS
There were no intraoperative complications. One major complication was observed: a patient developed septicemia that resolved after proper care. Clinical outcomes scores showed overall improvement in pain and physical function. During follow-up, the following complications were observed in the construct: screw breakage (14.8%), proximal/distal transsacral rod detachment (11.1%), radiolucency around the transsacral rod (52%), and cephalic rod migration (24%). Disc height gain was reported early after surgery, but at the 24-month follow-up the disc space was diminished in comparison with the preoperative status. Compared with preoperative values, the 24-month results showed loss of segmental lordosis. Only 22% of all treated levels were considered to have solid fusion at the 24-month radiological evaluation.

CONCLUSIONS
Patients undergoing presacral 2-level AxiaLIF experienced satisfactory short-term clinical outcomes; however, complications were commonly seen on imaging studies obtained 24 months postoperatively. Additional studies are required to better understand the 2-level indications for this technique.

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Intradural spinal metastases: a surgical series of 15 patients

Acta Neurochir (2012) 154:871–877. DOI 10.1007/s00701-012-1313-5

Intradural spinal metastases are rare, and little is known regarding surgical indications and outcomes.

Methods A retrospective search identified adults with intradural spinal metastases operated on at the Mayo Clinic from 1994-2011. Data were collected regarding demographics, tumor type and location, and outcomes.

Results Fifteen patients with intradural spinal metastases were investigated. The age range was 38-74 years (mean= 55 years; ±SD=11.1). Predominant tumor location and type were lumbosacral and adenocarcinoma, respectively: 3 intramedullary and 12 extramedullary. Patients were operated on to relieve or prevent progressive/intractable neurological sequelae and/or pain. Of 13 who underwent resection, gross total removal was reported in 10; simple biopsy was performed in 2. There was one surgical complication, no medical complications, and no surgical mortality. At median follow-up of 1 month postoperatively, 10 of 15 patients were stable or improved. Of 13 patients who underwent resection, 10 were stable or improved. Of two patients who underwent biopsy, neither was stable or improved at follow-up. Using the Modified McCormick Scale, 11 of 15 patients were “functional” preoperatively and 4 went from “functional” preoperatively to “non-functional” postoperatively. Three of those four died within 60 days of surgery from systemic disease progression. Median hospital stay was 8 days. Ten of 15 patients died by the end of the study period, and the median survival of 15 patients was 5 months.

Conclusions With improved outcomes in metastatic cancer, more patients are encountered in practice. An aggressive surgical approach is warranted for extramedullary lesions, whereas caution is advised for intramedullary lesions. Postoperative functional decline is more likely due to systemic disease progression rather than surgery.

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Prevalence, Severity, and Impact of Foraminal and Canal Stenosis Among Adults With Degenerative Scoliosis

Neurosurgery 69:1181–1187, 2011 DOI: 10.1227/NEU.0b013e31822a9aeb

Management approaches for adult scoliosis are primarily based on adults with idiopathic scoliosis and extrapolated to adults with degenerative scoliosis. However, the often substantially, but poorly defined, greater degenerative changes present in degenerative scoliosis impact the management of these patients.

OBJECTIVE: To assess the prevalence, severity, and impact of canal and foraminal stenosis in adults with degenerative scoliosis seeking operative treatment.

METHODS: A prospectively collected database of adult patients with deformity was reviewed for consecutive patients with degenerative scoliosis seeking surgical treatment, without prior corrective surgery. Patients completed the Oswestry Disability Index, SF-12, Scoliosis Research Society 22 questionnaire, and a pain numeric rating scale (0-10). Based on MRI or CT myelogram, the central canal and foraminae from T6 to S1 were graded for stenosis (normal or minimal/mild/moderate/severe).

RESULTS: Thirty-six patients were included (mean age, 68.9 years; range, 51-85). The mean leg pain numeric rating scale was 6.5, and the mean Oswestry Disability Index score was 53.2. At least 1 level of severe foraminal stenosis was identified in 97% of patients; 83% had maximum foraminal stenosis in the curve concavity. All but 1 patient reported significant radicular pain, including 78% with discrete and 19% with multiple radiculopathies. Of those with discrete radiculopathies, 76% had pain corresponding to areas of the most severe foraminal stenosis, and 24% had pain corresponding to areas of moderate stenosis.

CONCLUSION: Significant foraminal stenosis was prevalent in patients with degenerative scoliosis, and the distribution of leg pain corresponded to levels of moderate or severe foraminal stenosis. Failure to address symptomatic foraminal stenosis when surgically treating adult degenerative scoliosis may negatively impact clinical outcomes.

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Chordomas of the skull base and cervical spine: clinical outcomes associated with a multimodal surgical resection combined with proton-beam radiation in 40 patients

Neurosurg Rev DOI 10.1007/s10143-011-0334-5

Previous studies of chordoma have focused on either surgery, radiotherapy, or particular tumor locations. This paper reviewed the outcomes of surgery and proton radiotherapy with various tumor locations.

Between 2001 and 2008, 40 patients with chordomas of the skull base and cervical spine had surgery at our hospital. Most patients received proton therapy. Their clinical course was reviewed. Age, sex, tumor location, timing of surgery, extent of resection, and chondroid appearance were evaluated in regard to the progression-free survival (PFS) and overall survival (OS). The primary surgery (PS) group was analyzed independently. The extensive resection rate was 42.5%. Permanent neurological morbidity was seen in 3.8%. Radiotherapy was performed in 75% and the mean dose was 68.9 cobalt gray equivalents. The median followup was 56.5 months. The 5-year PFS and OS rates were 70% and 83.4%, respectively. Metastasis was seen in 12.5%. The tumor location at the cranio-cervical junction (CCJ) was associated with a lower PFS (P=0.007). In the PS group, a younger age and the CCJ location were related to a lower PFS (P=0.008 and P<0.001, respectively). The CCJ location was also related to a lower OS (P=0.043) and it was more common in young patients (P=0.002). Among the survivors, the median of the last Karnofsky Performance Scale score was 80 with 25.7% of patients experiencing an increase and 11.4% experiencing a decrease.

Multimodal surgery and proton therapy thus improved the chordoma treatment. The CCJ location and a younger age are risks for disease progression.

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Assessment of adjacent-segment mobility after cervical disc replacement versus fusion: RCT with 1 year’s results

Eur Spine J (2011) 20:934–941. DOI 10.1007/s00586-010-1588-2

Disc prostheses have been designed to restore and maintain cervical segmental motion and reduce the accelerated degeneration of the adjacent level. There is no knowledge about the reaction of the neighboured asymptomatic segments after implantation of prostheses or fusion. The effects of these procedures to segmental movement of the uninvolved vertebrae have not been subjected to studies so far.

The objective of this study was to compare the segmental motion following cervical disc replacement versus fusion and the correlation to the clinical outcome. Another aim was to compare the segmental motion of the asymptomatic segments above the treated ones and to compare both with Roentgen stereometric analysis (RSA) including the asymptomatic segments.

20 patients with one-level cervical radiculopathy scheduled for surgery were randomized to arthroplasty (10 patients, study group) or anterior cervical discectomy and fusion (10 patients, control group). Clinical results were evaluated using Visual Analogue Scale and Neck Disability Index. RSA was performed immediately postoperative, after 6 and 12 months.

The adjacent segment showed a significantly higher segmental motion in all three-dimensional axes in comparison to the segment treated with prostheses (P< 0.05). In the fusion group the segmental motion of the adjacent segment was significantly higher in all three dimensional axes (P< 0.05) at each examination time. When the adjacent level of both groups is compared, the fusion group could show a higher segmental motion in all three-dimensional axes, but without significant difference (P> 0.05) 1 year after surgery. Regarding the clinical results, there was no significant difference in pain relief between both groups (P> 0.05).

In conclusion, the adjacent segment could show a higher segmental motion, when compared with the segment either treated with prostheses or fusion. There was no significant difference in segmental motion adjacent to prosthesis or fusion. Clinical results did also show no significant difference in pain relief between both groups.

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Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures

J Neurosurg Spine 14:561–569, 2011. DOI: 10.3171/2010.12.SPINE10286

Osteoporotic vertebral compression fractures (VCFs) are a major cause of increased morbidity in older patients. This randomized controlled trial compared the efficacy of percutaneous vertebroplasty (PV) versus optimal medical therapy (OMT) in controlling pain and improving the quality of life (QOL) in patients with VCFs. Efficacy was measured as the incidence of new vertebral fractures after PV, restoration of vertebral body height (VBH), and correction of deformity.

Methods. Of 105 patients with acute osteoporotic VCFs, 82 were eligible for participation: 40 patients underwent PV and 42 received OMT. Primary outcomes were control of pain and improvement in QOL before treatment, and these were measured at 1 week and at 2, 6, 12, 24, and 36 months after the beginning of the treatment. Radiological evaluation to measure VBH and sagittal index was performed before and after treatment in both groups and after 36 months of follow-up.

Results. The authors found a statistically significant improvement in pain in the PV group compared with the OMT group at 1 week (difference -3.1, 95% CI -3.72 to -2.28; p < 0.001). The QOL improved significantly in the PV group (difference -14, 95% CI -15 to -12.82; p < 0.028). One week after PV, the average VBH restoration was 8 mm and the correction of deformity was 8°. The incidence of new fractures in the OMT group (13.3%) was higher than in the PV group (2.2%; p < 0.01).

Conclusions. The PV group had statistically significant improvements in visual analog scale and QOL scores maintained over 24 months, improved VBH maintained over 36 months, and fewer adjacent-level fractures compared with the OMT group.

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The Craniovertebral Junction Area and the Role of the Ligaments and Membranes

Neurosurgery 68:291–301, 2011 DOI: 10.1227/NEU.0b013e3182011262

Traumatic injuries of the craniovertebral junction (CVJ) area are common and frequently the outcome of motor vehicle accidents, falls, and diving accidents.

To define and characterize CVJ traumatic injuries, some international classifications are currently in use, and they are thought and focused on junction bone fracture. However, recent data point out a major important role of the CVJ ligaments and membranes in traumatic injuries with a secondary function of the osseous structures.

Emphasizing the correct role of the ligaments and membranes is extremely important for determining appropriate medical or surgical planning for patients and also to design new CVJ injury classifications.

We reviewed every recent major publication on the ligaments and membranes of the CVJ area. We divided the information into sections concerning anatomy, embryology, biomechanics, trauma, and CVJ bone fractures.

A role of the ligaments and membranes in the traumatic injuries of the CVJ area has often been recognized; but only recently, with the increase in the knowledge of the anatomic and biomechanical junction area, supported by neuroradiological tools (magnetic resonance imaging) and a more detailed traumatic injuries assessment, has the role of the ligaments and membranes been highlighted.

Ligaments and membranes have a pivotal role in each junctional ability and are the key to orienting any medical or surgical indications in this unique area of the spine.

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Outpatient Anterior Cervical Discectomy and Fusion: Indications and Clinical Experience in a Consecutive Series of 390 Patients

Neurosurg Q 2010;20:107–110

Objective: To assess the safety and efficacy of outpatient anterior cervical discectomy and fusion (ACDF) carried out on outpatients.

Methods: We retrospectively reviewed the records of 390 consecutive patients who underwent outpatient ACDF between September 2002 and September 2007 to assess the safety and efficacy of outpatient anterior cervical surgery. The mean age of the patient sample was 46; 56% were female and 44% were male. Indications for surgery consisted of cervical radiculopathy or myelopathy. Charts were reviewed to define patient demographics and medical comorbidities. Operative data, including levels treated, surgery time, time to discharge, and intraoperative complications were collected. Clinical outcomes were collected using the PhDx Clinical Outcomes Database. Need for hospital transfer from the ambulatory surgical center, emergency room visits, and subsequent hospital admission in the perioperative period were determined from patient records. Complications, patient satisfaction, and outcome were ascertained through review of notes from the first postoperative visit.

Results: There was no mortality and there were no major complications. Out of 390 patients, operation was carried out at 1 level in 223 patients, at 2 levels in 143, and at 3 levels in 24. Pain was present in 99%, motor deficit in 31%, and myelopathy in 14%. Twenty-five percent were hypertensive, 5% were diabetic, and 2% had coronary artery disease. The incidence of hospital transfer for ACDF related complications was <1%, emergency room visits <1% and subsequent hospitalization <1%. At the time of the first postoperative visit 92% of patients believed that they were improved and only 1% of patients had transiently increased radicular weakness.

Conclusion: Outpatient ACDF is safe and efficacious in selected patients.

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The major complications of transpedicular vertebroplasty

J Neurosurg Spine 11:607–613, 2009. DOI: 10.3171/2009.4.SPINE08466

Vertebroplasty is a well-known technique used to treat pain associated with vertebral. Despite a success rate of up to 90% in different series, the procedure is often associated such as cord and root compression, epidural and subdural hematomas (SDHs), and other minor complications. In this study, the authors discuss the major complications of and their clinical implications during the postoperative course.

Methods. Vertebroplasty was performed in 12 vertebrae of 7 patients. Five patients had fractures, 1 had tumoral compression fractures, and 1 had a traumatic fracture. Two leakage, 1 had epidural leakage, 1 had subdural cement leakage, 2 had a spinal SDH, and after the procedure.

Results. Three patients had paraparesis (2 had SDHs and 1 had epidural cement leakage), 3 had root symptoms, and 1 had lower back pain. Two of the 3 patients with paraparesis recovered after evacuation of the SDH and subdural cement; however, 1 patient with paraparesis did not recover after epidural cement leakage, despite cement evacuation. Two patients with foraminal leakage and 1 with subdural cement leakage had root symptoms and recovered after evacuation and conservative treatment. The patient with the split fracture had no neurological symptoms and recovered with conservative treatment.

Conclusions. Transpedicular vertebroplasty may have major complications, such as a spinal SDH and/or cement leakage into the epidural and subdural spaces, even when performed by experienced spinal surgeons. Early diagnosis with CT and intervention may prevent worsening of these complications.

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