Surgical treatment of metastatic spine disease.

The results of surgical intervention for metastatic disease on 56 consecutive patients since 1980 were reviewed. Two patients underwent a second procedure to stabilize remote levels of spinal involvement, for a total of 58 surgeries. All 56 patients presented with pain. After surgery, significant relief was noted by 51 (91%). Twenty-seven patients presented with neurologic compromise. After operation, neurologic improvement was noted in 20 (74%). No patient's neurologic function deteriorated secondary to surgical intervention. Twenty-one patients were bedridden before surgery secondary to pain or paresis. After operation, improvement in activity level was achieved in 16 (76%) of these patients. In summary, the goal of surgical treatment of metastatic spine disease is to improve the quality of the remaining life, by the relief of pain and preservation or restoration of neurologic function. The dismal consequences of prolonged bed rest, paraplegia, and a painful premature demise can be avoided with thoughtful and timely surgical intervention.     

Surgical treatment of metastatic tumors of the spine

The goal of surgical treatment of metastatic spinal tumors is to maintain neurologic functioning without pain for the duration of the life expectancy. Of 28 patients in this series, 25 who had metastasis in the vertebral body underwent direct decompression by removal of the tumor, followed by vertebral reconstruction. A combined anterior or posterior instrumentation provided rigid spinal stability immediately after surgery. Three patients with involvement of the posterior part of the vertebra were treated by laminectomy for removal of the tumor, followed by posterior instrumentation. As a result, of nine patients who are alive with improved neurologic functions, seven have been ambulatory for an average duration of 13 months. Of 19 patients who have already died, recurrence of neurologic deficits was observed in five (26%), and 14 had no neurologic deterioration until they succumbed to the malignancy. Removal of the tumor and reconstructive surgery may be expected to produce satisfactory results.     

胸腰椎转移瘤的外科治疗策略和效果分析

目的：探讨胸腰椎转移瘤的外科治疗策略和效果。方法：回顾性分析2009年1月到2010年12月收治的行外科手术干预治疗并获得随访的胸腰椎转移瘤患者共42例。男30例,女12例;平均年龄56.8岁（28～76岁）;胸椎转移瘤25例,腰椎转移瘤17例;单节段34例,双节段6例,3节段2 例。2例无症状,40例有腰背部或下肢疼痛。18例脊髓功能受损,其中ASIA分级 A级5例,B级3例,C级4例,D级6例。Tomita评分2～7分,术前根据Tomita评分制定手术目标,根据Tomita外科分期制定具体手术方案,分别行全椎体切除,肿瘤彻底刮除及姑息性椎管减压稳定手术。术后1周、3个月、6个月、1年及2年对患者疼痛、脊髓功能、肿瘤局部控制、生存、内置物情况进行评估。结果：42例术中死亡1例。术后1周38例疼痛缓解,5例完全性瘫痪中2例神经功能恢复至E级,2例恢复至D级,1例未恢复,13例不全瘫痪者均有1级以上恢复。随访24～48个月,内固定物失效1例,5例局部肿瘤复发或失去控制。术后3个月、6个月、1年及2年存活率分别为95.2%、85.7%、58.2%和37.6%.结论：对于脊柱转移瘤患者,通过Tomita评分和外科分型选择合适手术方式,可缓解疼痛,改善神经功能,增加脊柱稳定性,控制局部病灶,提高患者生存质量。     

Elective antireflux surgery in the US: an analysis of national trends in utilization and inpatient outcomes from 2005 to 2010

Background

Previous research suggested that antireflux surgery reached its peak volume in the US more than a decade ago. Factors such as changes in population demographics and improvements in surgical outcomes may have reversed this decline. We sought to examine national trends in the management of antireflux surgery patients and identify patient and hospital characteristics associated with postoperative complications.

Methods

We analyzed data from the Nationwide Inpatient Sample to identify adults with gastroesophageal reflux disease or esophagitis who underwent elective antireflux surgery between 2005 and 2010. Patient and hospital characteristics were analyzed. A multivariate logistic regression model was used to identify characteristics associated with an increased risk of postoperative complications following laparoscopic antireflux surgery.

Results

The volume of elective antireflux surgery remained relatively stable between 2005 (n = 15,819) and 2010 (n = 18,780). The percentage of patients older than 64 years of age increased from 21.1 % in 2005 to 30.9 % in 2010 (p < 0.01), while the percentage with a Charlson score over 2 more than doubled (1.2–2.7 %; p < 0.01). Inpatient complication rates (6.3 vs. 6.6 %; p = 0.21) and mortality (0.08 vs. 0.21; p = 0.72) were unchanged. On multivariate analysis, patients older than 79 years were three times as likely to develop a complication (odds ratio [OR] 3.1; 95 % CI 2.1–4.5) as were patients with a Charlson score over 2 (OR 3.1; 95 % CI 2.2–4.3).

Conclusions

Today’s antireflux surgery patient population is a higher-risk cohort, but complication rates have remained stable and inpatient mortality has declined more than 50 % over the past decade. Given these findings, additional research is needed to understand why antireflux surgery is underutilized, with a decline of more than two-thirds since its peak in 1999.     

Evolution of treatment for metastatic spine disease

The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.     

Industry payments to spine surgeons from 2014 to 2019: trends and comparison of payments to spine surgeons versus all physicians

BACKGROUND CONTEXTThe ethics of industry payments to physicians and the potential impact on healthcare costs and research outcomes have long been topics of debate. Industry payments to spine surgeons are frequently scrutinized. Transparency of industry relationships with physicians provides insight into their possible impact on clinical decision-making and utilization of care.PURPOSE: To analyze trends in medical industry payments to spine surgeons and all physicians from 2014 to 2019, and further evaluate whether specific payments to spine surgeons vary based on company size.STUDY DESIGN/SETTINGCross-sectional investigation of publicly reported Center for Medicare and Medicaid Services (CMS) Open Payments Database (OPD)POPULATION SAMPLEAll US providers listed as receiving industry payments with further evaluation of payments to neurosurgeons and orthopedic spine surgeons.OUTCOME MEASURESMain measures were the magnitude and trends of industry general and research payments and subcategories of general payments, such as royalty/license and consulting fees, to spine surgeons and comparison to all physicians over the six-year period. Variations in payment patterns among spine device manufacturers with the highest reported level of spine surgeon payments in 2019.METHODSFrom 2014 to 2019 publicly reported general and research industry payments in the CMS OPD were analyzed. Trends in payments to all physicians were compared to trends in payments to neurosurgeons and orthopedic spine surgeons. Trends in payment patterns among spine device manufacturers with the highest payments in 2019 were determined. Linear regression analysis was completed to find statistically significant outcomes.RESULTSOur investigation found an aggregate of $42,710,365,196 general and research payments reported to all physicians over the 6-year period, 2.6% ($1,112,936,203) of which went to spine surgeons. Industry general and research payments to spine surgeons decreased by 17.5% ($195,571,109, 2014; $161,283,683, 2019), while increasing by 8.7% ($6,706,208,391, 2014; $7,288,003,832, 2019) to all physicians. Industry research payments to spine surgeons were notably low each year and decreased to only 0.5% of research payments made to all physicians in 2019. Median payment received by spine surgeons as well as the overall distribution of payments to the 75th and 95th percentile significantly increased over the six-year period in comparison to the stable distribution of payments to all physicians. Top eight spine device manufactures with the highest level of spine surgeon payments accounted for 72.9% payments in 2014 but decreased payments by 17.6% to 2019 ($120,409,083.75, 2014; $99,283,264.49, 2019).CONCLUSIONSIndustry general and research payments to all physicians increased from 2014 to 2019 but decreased to spine surgeons, largely due to decreasing payments from eight device manufacturers with the highest level of surgeon payments. A small subset of spine surgeons continues to receive increasing payments. The implications of decreasing investments in research by industry and of large payments made to a small group of spine surgeons bears cautious oversight, both for the future of the specialty and any impact on patient care outcomes.     

前方入路手术治疗上胸椎转移瘤

目的:探讨前方入路行上胸椎肿瘤切除、椎体重建、钛板内固定的技术及方法,分析手术治疗效果及相关并发症。方法:2004年6月~2011年7月我科收治上胸椎(T1~T4)转移瘤患者17例,其中男6例,女11例,年龄55,1±7.3岁(47~68岁)。术前神经功能按Frankel分级:B级3例,C级4例,D级8例,E级2例。肿瘤位置:T1 7例,T2 5例,T3 3例,T4 2例。按Tokuhashi脊柱转移瘤评分系统评分为9~12分;根据WBB分区理论肿瘤病灶位于4~9区。对于T1椎体病灶患者采用低位下颈椎前方入路;对于T2~T4椎体病灶患者采用前方劈开胸骨经头臂干外侧间隙入路。结果:所有患者均能很好耐受手术,低位下颈椎前方入路手术时间为94.1士5.0min(90~102min),出血量为186.6±100.2ml(100~400ml);前方劈开胸骨经头臂干外侧间隙入路手术时间为121.0±165(100~150min),出血量为352.0±134.4ml(220~600ml)。术后病理学检查:6例来源于肺癌,5例来源于乳腺癌,2例来源于甲状腺癌,2例来源于胃肠道癌,2例来源不明。术后2例前方劈开胸骨经头臂干外侧间隙入路手术患者出现肺部感染、肺不张,经对症治疗后治愈。3例(其中1例为低位下颈椎前方入路手术患者)出现喉返神经牵拉伤致一过性声音嘶哑,术后1个月内声音恢复正常。随访19.7±9.8个月(6~48个月),9例患者神经功能有不同程度改善,其中3例Frankel分级B级患者2例改善为E级,1例改善为D级;4例C级2例改善到E级,2例改善到D级;2例D级患者改善到E级。5例患者在术后6~14个月因多处转移、全身衰竭死亡。结论:前方入路是治疗上胸椎转移瘤可供选择的有效入路,该入路可以充分显露前方椎体病变,有效切除病灶,彻底解除来自脊髓前方的压迫,改善患者症状。     

Surgical treatment of metastatic disease of the femur

Nearly every malignant neoplasm has been described as having the capability to metastasize to bone. Of the estimated 1.2 million new cases of cancer diagnosed annually, more than 50% will eventually demonstrate skeletal metastasis. Advances in systemic and radiation therapy have led to a considerable improvement in the prognosis of patients with metastatic disease. As a result, orthopaedic surgeons are being asked with increasing frequency to evaluate and treat the manifestations of skeletal metastases. The femur is commonly the site of large impending lesions and complete pathologic fractures. Although the health status of some patients may preclude operative intervention, established pathologic fractures of the femur and metastatic lesions deemed likely to progress to imminent fracture generally should be treated surgically. A rational approach to selection of the proper treatment for these problems includes consideration of the patient's overall medical condition and the type, location, size, and extent of the tumor. Treatment principles are the same regardless of location. A construct should ideally provide enough stability to allow immediate full weight bearing with enough durability to last the patient's expected lifetime. All areas of weakened bone should be addressed at the time of surgery in anticipation of disease progression. To minimize disease progression and possible implant or internal fixation failure, postoperative external-beam irradiation should be considered.     

Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease

INTRODUCTION

Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease.

METHODS

Retrospectively, four years of data were collected (2007–2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction.

RESULTS

A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32–87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1–39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age.

CONCLUSIONS

The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.     

An update on the nonoperative treatment of patients with metastatic bone disease

Bone metastases constitute a major problem in oncology because of their frequency and the therapeutic problems they present. Treatment indications depend on accurate diagnosis including histologic type, number, location, and sensitivity to treatment. New findings in the pathophysiology of bone metastases, new staging procedures, new treatment modalities, and better guidelines improve therapeutic effectiveness and the quality of life of patients. There are biologic and biomechanical indications for treatment. The goals of treatment are pain relief, restoration and maintenance of function, and the prevention of complications. The nonsurgical treatment of patients with metastatic bone disease includes analgesics, hormones, radiation therapy, cytotoxic drugs, radiopharmaceuticals, chemoablation, vertebroplasty, and bisphosphonates. The future of the treatment of patients with metastatic bone disease may involve the identification of biochemical markers. The author presents an overview of the current scientific concepts of metastatic bone disease and indications and specific strategies for nonoperative treatment of patients with tumor-induced osteolysis from metastatic bone disease.     

Surgical treatment of adult idiopathic scoliosis: long-term clinical radiographic outcomes

More adults are suffering from adult idiopathic scoliosis and seeking treatment for their spinal deformities. Adult idiopathic scoliosis can lead to painful spinal osteoarthritis, progressive deformity, spinal stenosis with radiculopathy, muscle fatigue from coronal and sagittal plane imbalance, and psychological effects with a visible deformity. Primary treatment of such conditions is conservative; however, some patients are resistant to conservative treatment or are not candidates for it, and they require surgery. Back pain is likely the most common indication for surgical treatment of scoliosis in adult patients. Pedicle screws offer 3-column purchase and a longer arm compared with hook placement on the lamina. This study is a retrospective analysis of a consecutive series of patients with adult idiopathic scoliosis who were treated with pedicle screw placement. Significant back pain relief and satisfaction can be achieved and maintained over the long term. Restoration of coronal and sagittal balance, or improvement thereof, was achieved in all patients with balance problems. This study clarified several important characteristics of adult scoliosis, and we believe that useful conclusions can be drawn regarding its surgical indications and strategies: (1) pedicle screw construct can gain effective results for treatment of adult idiopathic scoliosis due to its perceived superior power of correction; (2) younger patients present for surgery for different reasons than older patients (progressive deformity or pain); and (3) pain improvement is a more reliable outcome in older patients than younger patients, although younger patients rarely have severe pain symptoms.     

Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients

Aggressive surgical management of spinal metastatic disease can provide improvement of neurological function and significant pain relief. However, there is limited literature analyzing such management as is pertains to individual histopathology of the primary tumor, which may be linked to overall prognosis for the patient. In this study, clinical outcomes were reviewed for patients undergoing spinal surgery for metastatic breast cancer. Respective review was done to identify all patients with breast cancer over an eight-year period at a major cancer center and then to select those with symptomatic spinal metastatic disease who underwent spinal surgery. Pre- and postoperative pain levels (visual analog scale [VAS]), analgesic medication usage, and modifed Frankel grade scores were compared on all patients who underwent surgery. Univariate and multivariate analyses were used to assess risks for complications. A total of 16,977 patients were diagnosed with breast cancer, and 479 patients (2.8%) were diagnosed with spinal metastases from breast cancer. Of these patients, 87 patients (18%) underwent 125 spinal surgeries. Of the 76 patients (87%) who were ambulatory preoperatively, the majority (98%) were still ambulatory. Of the 11 patients (13%) who were nonambulatory preoperatively, four patients were alive at 3 months postoperatively, three of which (75%) regained ambulation. The preoperative median VAS of six was significantly reduced to a median score of two at the time of discharge and at 3, 6, and 12 months postoperatively (P < 0.001 for all time points). A total of 39% of patients experienced complications; 87% were early (within 30 days of surgery), and 13% were late. Early major surgical complications were significantly greater when five or more levels were instrumented. In patients with spinal metastases specifically from breast cancer, aggressive surgical management provides significant pain relief and preservation or improvement of neurological function with an acceptably low rate of complications.