Journal of neurosurgery. Spine最新文献

Objective: Patients with spinal CSF leaks often have ventral dural abnormalities (type 1 CSF leaks); however, the pathological mechanism for developing dural abnormalities is unknown. The authors investigated whether calcified dural ligaments contribute to the development of ventral dural tears, which cause spinal CSF leaks.

Methods: Consecutive patients diagnosed with type 1 CSF leaks who had spiculated spinal lesions between 2010 and 2024 were included. Clinical, radiological, surgical, and histological findings were reviewed.

Results: Nineteen patients with type 1 CSF fistulas had spiculated spinal lesions (15 men; median age 47 years, range 28-71 years). Spiculated lesions showed a high density on CT, and the median lesion length was 3.5 mm (range 1.6-9.1 mm). Spiculated lesions were consistently located at the center of the ventral dural abnormalities, penetrated the dura mater, and were located in the high thoracic spine (T1-5) in 13 patients (68%) and in the low thoracic spine (T8-12) in 6 (32%). These spinal lesions were connected to the posterior longitudinal ligament, but not to the vertebral body or disc. Histologically, they did not include degenerative osteophytic or discogenic tissues, mostly comprised fibrotic tissues with some calcification, and were consistent with calcified dural ligaments.

Conclusions: The anatomical characteristics of spiculated spinal lesions associated with ventral dural abnormalities are consistent with those of calcified dural ligaments, referred to as Hofmann's ligaments. These ligaments are important for neurosurgeons, neurologists, and neuroradiologists who diagnose and treat type 1 CSF fistulas.

Objective: This study aimed to report changes in utilization and payment trends of low-back pain (LBP) interventions and the impact of nonsurgeon interventionalists on these changes.

Methods: Medicare Part B national summary data files were used to gather annual utilization and Centers for Medicare and Medicaid Services (CMS) payment data for LBP interventions from 2000 to 2021. Healthcare Common Procedure Coding System (HCPCS) codes were grouped as decompression, spinal fusion, sacroiliac (SI) joint fusion, epidural steroid injections (ESIs), physical therapy (PT), and chiropractic manipulation (Chiro). The total allowed services and payments were collected for each HCPCS group. CMS provider-level files, available from 2013 to 2021, were used to collect neurosurgeon, orthopedic surgeon, and nonsurgeon interventionalist (interventional radiology and pain management) data for each surgical HCPCS code group (decompression, spinal fusion, and SI joint fusion). The United States Consumer Price Index was used to adjust for inflation.

Results: From 2000 to 2021, there were 339,720,725 Medicare-approved interventions and payments of approximately $21 billion for LBP (percentage of cumulative payments: 41.8% Chiro, 16.5% ESI, 14.4% spinal fusion, 14.3% PT, 10.2% decompression, and 0.4% SI joint fusion). In a subgroup analysis, spinal fusions for Medicare patients were performed by orthopedic surgeons (59.2%), neurosurgeons (40.6%), and nonsurgeon interventionalists (< 1%) from 2013 to 2021. From 2013 to 2021, neurosurgeon and orthopedic surgeon fusion utilization each grew by < 3% and associated Medicare payments to each specialty declined by 1% each year. During the same period, nonsurgeon interventionalist utilization grew 26% each year and associated Medicare payments to nonsurgeon interventionalists for spine fusions grew 62% each year. In a subgroup analysis, SI joint fusions for Medicare patients were performed by orthopedic surgeons (50.7%), neurosurgeons (24.8%), and nonsurgeon interventionalists (24.5%) from 2018 to 2021. Neurosurgeon utilization of SI joint fusion declined by 1% each year and associated Medicare payments to this group grew 2% each year. Orthopedic surgeon utilization of SI joint fusion declined 1% and associated Medicare payments to this group grew 4% each year. Nonsurgeon interventionalist use of SI joint fusions grew 415% and payments grew 435% each year.

Conclusions: The substantial growth in Medicare payments for surgical LBP interventions is disproportionally driven by nonsurgeon interventionalists. The exponential growth of nonsurgeon interventionalists performing spinal fusion surgeries, particularly SI joint fusions, largely accounts for the significant increase in Medicare expenditures.

Objective: The aim of this study was to compare the outcome of intralesional gross-total resection (GTR) followed by high-energy particle therapy with en bloc and intralesional resections.

Methods: A retrospective study of patients diagnosed with primary osteogenic sarcoma (OGS) of the spine between 2009 and 2020 was conducted. Demographic information, including age, affected site, tumor volume, and Weinstein-Boriani-Biagini stage, was collected. Additionally, information on metastases at diagnosis, length of stay, operating time, complications, planned surgical treatment, and radiotherapy was also collected. Outcome measures, including local recurrence (LR) and disease-specific survival (DSS), were compared using Kaplan-Meier curves.

Results: In total, 20 patients with a median age of 38 (IQR 23-60) years were included. The median follow-up was 15.7 (IQR 6.3-36.9) months. Eight patients underwent en bloc resection with a 38% (3 patients) LR rate and a median DSS of 26.4 months. Four patients received adjuvant high-energy particle therapy after planned GTR. Their median follow-up was 36 months; none of these patients experienced LR. Both the 1-year and 3-year DSSs were 100%. Another 8 patients underwent intralesional resection. Six of the 8 patients (75%) died of their disease, with a median survival of 7.3 (IQR 4.7-14) months.

Conclusions: GTR combined with adjuvant high-energy particle therapy appears to be a safe and effective alternative approach for patients with OGS of the spine when en bloc resection is not feasible. The results demonstrated a 3-year DSS of 100% and no major surgical complications.

Objective: Primary spinal cord gliomas are rare, and among these astrocytomas (WHO grade II) are much rarer. The optimal treatment strategy thus remains unclear. The authors conducted a multicenter study led by the Neurospinal Society of Japan (NSJ) to analyze treatment policies and outcomes. The aim was to present optimal treatment methods for spinal cord astrocytoma and to identify predictors of better outcomes.

Methods: Among 1033 consecutive cases of spinal cord intramedullary tumors treated surgically at 58 centers affiliated with the NSJ, 57 patients were diagnosed with diffuse astrocytoma (WHO grade II) and were enrolled in the present study. Among these 57 patients, treatment methods, outcomes, and tumor proliferation rate as evaluated by the MIB-1 staining index (SI) were analyzed, and the optimal treatment method for spinal cord astrocytomas (grade II) was determined. In addition, the authors searched for factors predicting better treatment outcomes.

Results: Treatment for spinal cord astrocytoma comprised three methods: surgery alone in 30 patients, adjuvant radiation therapy in 13 patients, and adjuvant chemoradiotherapy in 13 patients. One patient who did not undergo surgery was excluded from survival analysis. Treatment with surgery alone or surgery with radiotherapy was associated with significantly longer overall and progression-free survivals than that with adjuvant chemoradiotherapy. Patients treated with radiation therapy had a higher MIB-1 SI than those treated with surgery alone. The extent of tumor resection tended to correlate with longer survival. In contrast, postoperative neurological worsening showed the inverse order. Adjuvant chemoradiotherapy was associated with the shortest survival in both total cases and recurrent cases. The optimal cutoff value of MIB-1 SI for predicting longer survival by surgery alone was less than 4.0%.

Conclusions: The optimal treatment for spinal cord astrocytoma is maximal tumor resection without neurological impairment. When some tumor remains in patients with an MIB-1 SI less than 4.0%, a wait-and-see approach is optimal. If the MIB-1 SI is higher than 4.0%, local radiation therapy is recommended. Adjuvant chemotherapy is not recommended for the treatment of grade II spinal cord astrocytoma.

Objective: Patients with spinal cord astrocytomas (SCAs) are at high risk for CNS dissemination, yet comprehensive data on characteristics of dissemination are lacking. This study depicts the exact incidence and patterns of dissemination by analyzing data from a large-scale dataset of SCA.

Methods: The authors included 94 patients with SCA based on the 2021 WHO classification from 2011 to 2022, retrospectively collected their clinical and pathological characteristics, and analyzed factors influencing SCA dissemination.

Results: CNS dissemination, encompassing leptomeningeal spreading and/or subarachnoid seeding, was evaluated in 94 patients with and without H3 K27 alterations, with an overall dissemination rate reaching 85.0% at 5-year follow-up. Patients with altered H3 K27 had a significantly higher 5-year CNS dissemination rate than patients with H3 K27 wildtype status (95.2% vs 68.0%, p = 0.002). The median dissemination-free survival in H3 K27-altered patients was 14.37 (95% CI 2.84-25.89) months, significantly shorter than those with H3 K27 wildtype (statistics not calculated; p < 0.001). Based on univariate Cox regression analysis, H3 K27M alteration, higher histopathological grade, Ki-67 index (≥ 10%), and tumor length (≥ 4 segments) were identified as potential factors associated with CNS dissemination in SCAs. Multivariate Cox regression analysis revealed that H3 K27M alteration appeared to be a risk factor for this phenomenon (HR 2.089, 95% CI 0.940-4.642, p = 0.070). Following dissemination, H3 K27-altered patients had a median postdissemination survival of 8.83 (95% CI 7.13-10.54) months, which was significantly shorter than the 13.40 (95% CI 3.98-34.26) months in those with H3 K27 wildtype (p = 0.008).

Conclusions: Factors indicative of higher SCA malignancy, such as H3 K27M alteration, higher histopathological grade, Ki-67 index (≥ 10%), and tumor length (≥ 4 segments), were similarly suggestive of higher rates of dissemination. The occurrence of dissemination is closely associated with the outcome events in patients with SCA.