Journal of neurosurgery. Spine最新文献

Objective: The aims of this study were to clarify the relationship between the combined forward flexion capacity of the lumbar spine and hip joint, referred to as TrunkAflex, and Lumbar Stiffness Disability Index (LSDI) scores in patients following lumbar spine surgery, and to assess whether TrunkAflex better reflects disabilities with activities of daily living (ADL) than the number of fused segments or lumbar spine flexion alone.

Methods: This prospective, cross-sectional, multicenter study included 147 patients who underwent lumbar spine surgery and completed LSDI questionnaires. Lateral radiographs were obtained in the maximum seated flexion position. Radiographic parameters included pelvic incidence (PI)-corrected lumbar lordosis in flexion (PI-LLflex), representing lumbar spine flexion ability, pelvic femoral angle in flexion (PFAflex), representing hip joint flexion ability, and TrunkAflex, defined as the angle between the axis of the L1 vertebral body and the proximal femoral shaft, mathematically expressed as the sum of PI-LLflex and PFAflex. Correlation analyses were used to determine the relationships between LSDI and these parameters. Subgroup analyses were performed to compare the lumbar fusion (upper instrumented vertebra [UIV] at L1 or below) and thoracolumbar fusion (UIV at T12 or above) groups.

Results: The LSDI score was significantly correlated with the number of fused segments (r = 0.328, p < 0.01), and PI-LLflex showed a significant correlation with LSDI (r = -0.354, p < 0.01). However, TrunkAflex demonstrated the strongest correlation with LSDI (r = -0.491, p < 0.01). Subgroup analysis revealed that PI-LLflex was more influential in the lumbar fusion group, while PFAflex was more impactful in the thoracolumbar fusion group. Nevertheless, TrunkAflex consistently showed the strongest correlation with LSDI across all groups. Notably, TrunkAflex was minimally influenced by PI, making it a practical and consistent parameter for trunk forward flexion assessment.

Conclusions: This study demonstrated that the combined forward flexion ability of the lumbar spine and hip joint, represented by TrunkAflex, is a stronger predictor of LSDI scores than the number of fused segments or lumbar spine flexion alone, irrespective of the fusion range. Preoperative assessment of hip joint function is particularly important when planning long-segment fusion, and adjusting surgical strategies to preserve appropriate TrunkAflex may contribute to better postoperative ADL outcomes.

Objective: Unstable pathological spine fractures are common in patients with cancer. Minimally invasive percutaneous instrumentation has emerged as a less traumatic alternative to conventional open spinal fixation. As cancer patient survival continues to improve, the long-term durability of this strategy and the likelihood of achieving segmental fusion remain insufficiently studied. This study aimed to describe the clinical, oncological, and surgical characteristics, including outcomes and facet fusion rates, in patients with metastatic spine disease undergoing percutaneous pedicle screw fixation at a tertiary cancer center.

Methods: This retrospective cohort study evaluated patients treated using percutaneous pedicle screws and rods between 2014 and 2023. Patients without bone grafting and with postoperative imaging follow-up of more than 30 days were included. Demographic, clinical, oncological, surgical, and radiological data were collected. Postoperative CT scans were used to assess hardware breakage, screw loosening, and facet fusion, which was defined as complete bone bridging between adjacent vertebrae.

Results: A total of 109 patients (114 constructs) were evaluated. Most patients were nonsmokers, White, and obese, with a high prevalence of prior radiotherapy and low-grade epidural tumor at the unstable level. Short constructs (1 level above and below the affected vertebra) were used in 60% of cases. Cement augmentation of pedicle screws was performed in 97% of procedures. Postoperative CT scans demonstrated some degree of cement extravasation in 85.7% of cases, but all were asymptomatic. Pain significantly improved postoperatively (visual analog scale score improvement from 6.1 to 2.5; p < 0.01). Hardware failure occurred in 6.1% of cases (n = 7), and 12.3% (n = 14) required reintervention. Segmental facet fusion occurred in 44.7% of patients, although the number of facets fused per number of facets fixed remained low at all time points: 7% at 6 months, 10% at 1 year, and 24% at 2 years.

Conclusions: Percutaneous pedicle screw and rod constructs provide effective and durable spinal stabilization with low complication rates and significant pain reduction. Segmental facet fusion was observed in nearly half of the patients in this study, but clinical benefits and hardware durability were independent of radiographic evidence of arthrodesis.

Objective: Chordoma and chondrosarcoma are rare malignant bone tumors of the spine and sacrum. While en bloc resection with wide or marginal margins (Enneking appropriate [EA]) is considered the standard of care, the role of radiation therapy (RT) in the management of these traditionally radioresistant tumors remains controversial. This retrospective study aimed to evaluate treatment strategies with a focus on overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) patterns and analyze variables associated with these outcomes.

Methods: A retrospective cohort study was conducted at Vancouver General Hospital including patients with chordoma or low-grade chondrosarcoma of the mobile spine or sacrum treated surgically between 2009 and 2023. Patients were categorized into 1 of 4 groups: 1) en bloc EA resection without RT, 2) en bloc Enneking inappropriate (EI) resection with RT, 3) en bloc EI resection without RT, and 4) planned intralesional (IL) resection with or without RT. Primary outcomes were OS, DFS, and LRFS. Multivariable Cox regression was used to identify variables associated with these outcomes.

Results: Sixty-two patients had a median follow-up of 5.3 years. The 5-year OS, DFS, and LRFS rates were 78%, 65%, and 73%, respectively. Patients undergoing EA resection or en bloc EI resection with RT had superior OS and LRFS compared to en bloc EI resection without RT (OS 93% vs 88% vs 71%, p < 0.05; LRFS 82% vs 88% vs 52%, p < 0.05). DFS was highest in the en bloc EI resection with RT group (87%) compared to EA resection (74%; p < 0.05) and en bloc EI resection without RT (39%; p < 0.05). On multivariable analysis, age ≥ 65 years and en bloc EI resection without RT were associated with decreased OS, while en bloc EI resection without RT was the only variable independently associated with worse DFS and LRFS. All patients who underwent a planned IL resection died within 5 years.

Conclusions: This study highlights the complexity of achieving EA margins in en bloc resections for spinal chordoma and chondrosarcoma. In cases in which EA resection is not feasible, adjuvant high-dose RT appears to mitigate the negative impact of EI surgery and should be strongly considered. Further studies with longer follow-up durations are warranted to confirm these findings and optimize multimodal treatment strategies.

Objective: Chordomas are rare, locally aggressive primary neoplasms. Resection with negative margins is the primary recommended therapeutic approach, while adjuvant radiotherapy and chemotherapy can also play a role in their treatment in certain situations, including lesions with positive margins or those that are poorly differentiated or dedifferentiated. Cervical spine chordomas pose significant surgical challenges given their proximity to critical anatomical structures and the mechanical constraints of the cervical spine. In the current case series, authors aimed to explore the clinical and patient-reported outcomes (PROs) of the surgical treatment of cervical chordomas in a large multicenter cohort.

Methods: This multicenter case series analysis utilized data from the prospectively collected Primary Tumor Research and Outcomes Network (PTRON) registry, from its inception (May 16, 2016) to data extraction (February 29, 2024). The study population was restricted to patients with histologically confirmed cervical chordomas involving levels C0-7, who underwent surgical treatment at one of the participating centers, and for whom both the initially planned and postoperatively pathologically confirmed surgical margins were documented. Patient demographics, tumor characteristics, surgical and adjuvant treatments, local recurrence-free survival (LRFS), overall survival (OS), and perioperative adverse events were retrieved. PROs included the Spine Oncology Study Group Outcomes Questionnaire version 2.0 (SOSGOQ2.0), EQ-5D, and SF-36 version 2.0 (SF-36v2).

Results: Thirty-eight patients were identified, 12 of whom underwent true en bloc resection (EBR), 18 of whom underwent deliberate intralesional resection, and 8 of whom underwent EBR after intralesional surgery or in whom EBR failed. True EBR led to better LRFS (92% vs 83% vs 63%, respectively) and OS (83% vs 39% vs 50%, respectively). Surgical adverse events within 1 year were more frequent with true EBR (100% vs 39% vs 75%, respectively). EQ-5D, SOSGOQ2.0, and SF-36v2 showed improvement with true EBR, whereas the trends for PROs from the other groups were more variable.

Conclusions: This multicenter case series analysis provides critical insights into the clinical outcomes and PROs in the largest cohort of surgically treated cervical spine chordomas described to date. It underscores the importance and challenges of wide resection for oncological control. It establishes the associated morbidity and provides an overview of PROs following surgery. These findings contribute valuable evidence to inform shared decision-making and optimize patient care.

Objective: Adult spinal deformity (ASD) surgery is complex and may lead to postoperative cervical deformity (CD) and/or proximal junctional kyphosis. The Roussouly classification describes four types of baseline thoracolumbar (TL) morphology, which differentially influence surgical outcomes. However, their role in predicting CD remains underexplored. This study aimed to stratify TL-ASD patients by Roussouly types and examine postoperative CD development patterns.

Methods: The authors included operative ASD patients with no prior fusion and complete radiographic data at baseline, 6 weeks, 1 year, and 2 years. Patients were categorized into Roussouly types 1-4 using baseline pelvic incidence and lumbar lordosis apex. CD was assessed using a point system: cervical sagittal vertical axis (cSVA) of 40-80 mm = 1 point, T1 slope minus cervical lordosis (TSCL) of 15°-20° = 1 point, cSVA > 80 mm = 2 points, and TSCL > 20° = 2 points. CD was defined as a score ≥ 2. Statistical comparisons and multivariate logistic regression were used to assess CD risk across Roussouly types.

Results: A total of 546 patients (77% female, mean age 60.9 ± 14.3 years, mean BMI 27.3 ± 5.7 kg/m2, mean Charlson Comorbidity Index score 1.7 ± 1.7) were included. The mean number of fused posterior levels was 10.6 ± 4.5, with a mean estimated blood loss of 1548 ± 1450 mL, mean operative time of 438 ± 180 minutes, and mean length of stay of 7.7 ± 4.2 days. At baseline, 239 (43.8%) patients met CD criteria. The Roussouly distribution was as follows: type 1 (8.4%), type 2 (12.6%), type 3 (47.3%), and type 4 (31.7%). Among 307 patients without baseline CD, 174 (31.9%) developed CD within 2 years: 99 (32.2%) at 6 weeks, 44 (14.3%) at 1 year, and 31 (10.1%) at 2 years. Type 2 patients had higher odds of developing CD at 2 years compared to type 3 patients (OR 2.15, p = 0.019). Type 4 patients had lower odds of developing CD (OR 0.22, p = 0.12).

Conclusions: Roussouly type influences the timing and likelihood of CD following ASD correction. Type 1 patients tended to develop CD earlier, while type 2 patients showed delayed onset. Type 4 morphology may be protective against CD.

Objective: The objective of this study was to evaluate the impact of four-rod (4R) constructs and interbody cages (IBCs) on pseudarthrosis and rod breakage (PA/RB) in patients with adult spinal deformity (ASD) who had undergone surgery with pelvic fixation and Schwab grade 2 osteotomies, using a combined finite element model (FEM) and clinical data analysis.

Methods: A validated FEM simulated Schwab grade 2 osteotomies at the L4-5 level in two-rod and 4R configurations, with or without IBCs at L4-5 and L5-S1. Rod strain and range of motion were calculated under a 7.5-Nm moment. Clinical analysis was conducted on ASD patients with pelvic fixation and Schwab grade 2 osteotomies and ≥ 2 years of follow-up. Patients were classified into 2 groups depending on the presence or absence of PA/RB. Demographic, surgical, radiographic, and patient-reported outcome measure (PROM) data were compared.

Results: The FEM analysis revealed maximal rod strain of 399 MPa at the osteotomy site in flexion. The 4R constructs and IBCs reduced strain to 114 MPa at L4-5 and 80 MPa at L5-S1. Among the 213 patients included in the study, PA/RB occurred in 61 (28.6%). Multivariate analysis revealed the use of 4R constructs (OR 0.331, 95% CI 0.16-0.71, p = 0.004) and IBCs (OR 0.46, 95% CI 0.23-0.94, p = 0.033) as protective factors. Patients with PA/RB experienced more unplanned reinterventions, worse scores on PROMs, and greater loss of sagittal alignment at 2 years postoperatively.

Conclusions: Constructs with 4Rs and IBCs in ASD surgeries with pelvic fixation and Schwab grade 2 osteotomies significantly reduced rod strain and decreased the risk of PA/RB, leading to better scores on PROMs and decreasing unplanned reinterventions and loss of alignment.

Objective: The aim of this study was to review the management and outcomes of a consecutive cohort of patients with spinal myxopapillary ependymoma (MPE) treated at the authors' institution over a 23-year period.

Methods: A retrospective review of all patients treated surgically for spinal MPEs at a single institution between May 1998 and August 2021 was performed. Preoperative and postoperative clinical data, imaging, and/or radiology reports were reviewed to identify patient presentation and outcomes as well as tumor size, location, CSF dissemination, and other features. Method and extent of resection were characterized and related to preoperative tumor characteristics and outcomes.

Results: Fifty-six patients underwent 60 index surgical procedures at a single institution, including 4 surgeries for resection of a solitary drop sacral metastasis. The median postoperative follow-up was 126 months (range 22-304 months). En bloc gross-total resection (EGTR) was performed in 15 cases, marginal GTR (MGTR) in 17, piecemeal GTR (PGTR) in 6, piecemeal near-total resection (PNTR) in 9, and subtotal resection (STR) in 13 cases. Of the 55 primary filum terminale MPEs, 40 (73%) arose proximally, with their inferior tumor margin located at or above the L3 vertebral body. Nearly all patients who underwent EGTR (14/15) or MGTR (17/17) had MPEs that originated in the proximal filum terminale. In contrast, 10 of 13 patients who underwent STR had a distal MPE origin (below L3). CSF tumor dissemination, including drop metastases, was identified in 19.6% (11/56) of patients. Tumor size, especially width, significantly influenced the method of complete resection: the mean width of tumors resected with EGTR was 1.0 cm (range 0.4-1.7 cm) while the mean width of MGTR tumors was 1.5 cm (range 1.0-2.2 cm) (p < 0.001). Location, size, and marginal integrity of the tumor surface were important factors that influenced extent and quality of resection.

Conclusions: MPEs are benign tumors that arise predominantly from the filum terminale. Resection can be curative, especially for well-marginated tumors arising from the proximal filum terminale. Despite their benign nature, the tumors' lack of a capsule, friable tumor consistency, and frequent direct contact with the CSF and cauda equina create a propensity for local recurrence and CSF dissemination, especially for larger and distally originating tumors. Thus, long-term follow-up is recommended for all patients as is early surgical intervention for small, incidental MPEs.