Outcomes of Surgical Treatment for Extradural Benign Primary Spinal Tumors in Patients Younger than 25 Years: An Ambispective International Multicenter Study

Extradural primary spinal tumors were retrospectively analyzed from a prospective database of 1495 cases. All subjects with benign primary tumors under the age of 25 years, who were enrolled between 1990 and 2012 (Median FU was 2.4 years), were identified. Patient- and case-related characteristics were collected and statistically analyzed. Results: 161 patients (66f;95m; age 17.0 ± 4.7 years at time of diagnosis) were identified. The most common tumors were osteoblastomas n = 53 (32.9%), osteoid osteomas n = 45 (28.0%), and aneurysmal bone cysts n = 32 (19.9%). The tumor grade, according to the Enneking Classification S1/S2/S3, was 14/73/74 (8.7/45.3/46.0%), respectively. Tumor-related pain was present in 156 (96.9%) patients. Diagnosis was achieved by biopsies in 2/3 of the cases. Spinal fixation was used in >50% of the cases. Resection was Enneking appropriate in n = 100 (62.1%) of cases. Local recurrence occurred in 21 (13.1%) patients. Two patients died within a 10-year follow-up period. Conclusion: This is one of the largest international multicenter cohorts of young patients surgically treated for benign spinal tumors. The heterogenic young patient cohort presented at a mid-term follow-up without a correlation between the grade of aggressiveness in resection and local recurrence rates. Further prospective data are required to identify prognostic factors that determine oncological and functional outcomes for young patients suffering from these rare tumors

Complex tumor defect reconstruction of the thoracolumbar spine

Durch die Einführung onkologisch suffizienter Resektionen an der thorakolumbalen Wirbelsäule nehmen komplexe Rekonstruktionen tumorbedingter mono- und multisegmentaler vertebraler Destruktionen einen wachsenden Stellenwert in der muskuloskeletalen Tumorchirurgie ein. Trotz aller Erfahrungen mit stabilisierenden Wirbelsäuleneingriffen liegen nur unzureichende biomechanische Daten über den Wiederaufbau subtotaler und totaler segmentaler Defekte vor. Vor diesem Hintergrund wurde ein biomechanischer Versuchsaufbau zur Rekonstruktion nach En-bloc-Spondylektomie in einem Wirbelsäulensimulator etabliert. Unter der Verwendung humaner Präparate und Belastung mit reinen Momenten konnten reliable Stabilitätsbestimmungen durchgeführt werden. In einer ersten Untersuchung wurde gezeigt, dass die von extern auf die Implantate applizierten Kräfte für die Primärstabilität einen nachrangigen Effekt besitzen, während die Anzahl der dorsal instrumentierten Segmente die entscheidende Determinante für die Stabilität des Konstrukts im Modell darstellte. Aufgrund der höheren mechanischen Effektivität von Rekonstruktionen der ventralen Wirbelsäule wurde in einer zweiten Untersuchung der Einfluss technisch differenter VBR-Systeme und einer optionalen antero-lateralen Abstützung bestimmt. Mit unterschiedlichen Typen von VBR-Systemen konnte keine Veränderung der Primärstabilität erreicht werden. Die Implantation eines antero-lateralen Plattensystems zeigte nur in Kombination mit kurzen dorsalen Stabilisierungen einen zusätzlichen stabilisierenden Effekt. Es ist daher bei ausreichender dorsaler Stabilität in dieser Konstellation verzichtbar. In einem weiteren biomechanischen Versuchsaufbau wurde die Überlegenheit eines winkelstabilen gegenüber einem polyaxialen Plattensystem bei der isolierten Rekonstruktion eines maximierten Korpektomie-Defekts durch Bestimmung der Primär- und Sekundärstabilität nachgewiesen. Dabei ließen sich den mechanischen Charakteristika entsprechende Versagensmuster beobachten. Die Untersuchung der Stabilität der Verankerung der Plattensysteme im Knochen mit reduzierter BMD zeigte wiederum eine Überlegenheit des winkelstabilen Systems. Die in der klinischen Praxis definierten Algorithmen ermöglichen die standardisierte tumorchirurgische Therapie von Raumforderungen der Wirbelsäule. Im Vergleich zu intraläsionalen Resektionen konnten mit der En-bloc-Spondylektomie für ein Patientenkollektiv die Lokalrezidivrate drastisch reduziert, eine längere Gesamtüberlebenszeit erreicht sowie eine akzeptable physische und psychische Lebensqualität erzielt werden. Die onkologisch suffiziente Resektion ist nach den vorliegenden Ergebnissen in indizierten Fällen und im Zusammenspiel mit systemischen Therapieformen die maßgebliche Grundlage für eine erfolgreiche onkologische Behandlung. Die erlangten biomechanischen Erkenntnisse nehmen dabei direkten Einfluss auf die intraoperative Strategie der Rekonstruktion. Die konsekutiv erzielte Rekonstruktions- und Wirbelsäulenstabilität hat wiederum einen entscheidenden Effekt auf die postoperative Schmerzintensität, Mobilität und Lebensqualität der betroffenen Patienten.Intra-, extracompartmental and multisegmental tumor localisations of sarcomas and solitary metastases at the thoracolumbar spine can effectively be resected by TES. By achieving wide to marginal resection margins the combination of surgical procedure and adjuvant therapies demonstrate low local recurrence rates. Development of metastatic disease underscores the necessity for further advances in (neo-) adjuvant therapies aiming at prevention of systemic tumor spread. Without denying the intraoperative and surgical risks of that challenging procedure and the relative high patients stress, postoperative oncosurgical results confirm and support the importance and efficiency of this procedure. Biomechanical data for this kind of resection is rare. In-vitro testing with human specimens in a spine simulator with pure moments is a widely accepted procedure. The number of posterior stabilised segments showed the highest influence on primary stability. Externally applied compression in contrast showed only minor stabilising effects. The characteristics of the vertebral body replacement system demonstrated no difference for the stability. Anterior plating was more effective with angular stable implants. Use of therapeutical algorithms, careful patient selection, interdisciplinary surgical planning and cooperation, aggressive management of complications together with extensive experience in spine tumor surgery and reconstruction are essential prerequisites for good oncological results, low complication rates and acceptable functional results

Cement augmentation in a thoracolumbar fracture model

Einleitung: Die operative Versorgung von pathologischen thorakolumbalen Frakturen durch Zementaugmentationen erlaubt die frühfunktionelle Patientenmobilisation. Aus biomechanischer Sicht sind dabei das Ausmaß der Reposition und deren Stabilisierung ebenso wichtig wie bei nicht-pathologischen Wirbelsäulenfrakturen. Im Falle der Ballonkyphoplastie (BKP) ist bislang unklar, ob die Deflation des Ballons einen negativen Einfluss auf das Repositionsergebnis hat. Ferner ist die Rolle von Materialkombinationen zum Erhalt der Reposition unklar. Im Rahmen einer biomechanischen in-vitro Studie wurden die Unterschiede der BKP und des Vertebral Body Stenting (VBS) in Bezug auf die kyphotische Fehlstellung untersucht. Material und Methoden: Zwölf bisegmentale thorakolumbale Präparate (6x Th12-L2, 6x L3-L5; Alter zum Zeitpunkt des Todes 76,3 Jahre, Range 63-89 Jahre; Geschlechtsverteilung m:w/3:3, Knochendichte 76,8 mg/cm3, SD 10,9 mg/cm3) wurden mit 7,5 Nm in einem Wirbelsäulensimulator zur Bestimmung der Primär- und der Sekundärstabilität getestet. Im Anschluss an die Flexibilitäts-Testung des intakten Präparates folgte durch eine exzentrische Belastung die standardisierte Frakturierung und anschließende Reposition mit BKP oder VBS gegen ein Flexionsmoment von 2,5 Nm. Alle Präparate wurden nach drei aufsteigenden zyklischen Flexionsbelastungen in einer Materialtestungsmaschine im Wirbelsäulensimulator untersucht. Der Kyphosewinkel des Indexwirbels wurde nativ-radiologisch bestimmt. Results: Beide Augmentationstechniken erreichten in diesem Model eine vergleichbare Wiederaufrichtung der Frakturen gegen ein relativ hohes Biegemoment. Allerdings erreicht keine der Techniken die Werte des intakten Präparates. Während den zyklischen Belastungen zeigte sowohl der Höhenverlust als auch die elastische Verformung für beide Techniken gleichsinnige Ergebnisse. Obwohl sich der Deflationseffekt beim VBS kleiner zeigte im Vergleich zur BKP (P 0.05) konnte kein signifikanter Unterschied in Bezug auf die Kyphosekorrektur gezeigt werden. Zusammenfassung: Beide Techniken konnten eine Wiederherstellung der Wirbelkörperhöhe nach Fraktur zeigen. Der Deflationseffekt war dabei beim VBS geringer als bei der BKP. Hohe Flexionsmomente beim Einbringen des Zements limitieren die Effektivität der Reposition durch Zementaugmentations-Methoden.Study Design: In-vitro biomechanical investigation. Objective: To assess differences in kyphosis after balloon kyphoplasty (BKP) or vertebral body stenting (VBS). Summary of Background Data: Cement augmentation techniques allow early mobilization in patients with osteoporotic thoracolumbar fractures. Biomechanically, the grade of reduction and preservation are as important as in nonosteoporotic fractures. With BKP, it is as yet unclear whether balloon deflation has negative effects on the reduction and whether specific combinations of materials may be capable of maintaining the reduction. Methods: Twelve bisegmental human thoracolumbar specimens (6 T12L2, 6 L3L5; age at death 76.3 y, range 6389 y; femalemale ratio 3 : 3; bone mineral density 76.8 mg/cm3, SD 10.9 mg/cm3) were tested in a spine simulator with pure moments of 7.5 Nm to assess primary and secondary stability. Following flexibility testing of the intact specimens, an eccentric compression force induced standardized fractures, which were reduced using either BKP or VBS against a flexional moment of 2.5 Nm. Primary and secondary stability were assessed using range of motion (ROM) in a spine tester. The specimens were tested after each of three periods of cyclic flexion loading. The kyphotic angle of the index vertebra was measured radiographically. Results: The two techniques achieved comparable reduction against a relatively high bending moment in this model. Neither technique restored the stability of the intact state; with increasing loads, the ROM continuously declined to the level of the fractured specimen. During cyclic loading, height loss and elastic displacement showed similar results with the two augmentation techniques. Although the deflation effect on the kyphotic angle was lower with VBS (P 0.05), there were no significant differences between the techniques relative to angle restoration. Conclusions: Both augmentation techniques are able to restore vertebral body height following thoracolumbar fractures. The deflation effect on the kyphotic angle was less with VBS than with BKP. High flexion moments during implantation limit the effectiveness of reduction using cement augmentation methods.by Alexander C. DischAbweichender Titel laut Übersetzung der Verfasserin/des VerfassersEnth. u.a. 1 Veröff. d. Verf. aus den Jahren 2014Innsbruck, Med. Univ., Diss., 2015OeBB(VLID)76137

The prevalence of legal performance-enhancing substance use and potential cognitive and or physical doping in German recreational triathletes, assessed via the randomised response technique

This study investigated the use of performance-enhancing substances in recreational triathletes who were competing in German races at distances ranging from super-sprint to long-distance, as per the International Triathlon Union. The use of legal drugs and over-the-counter supplements over the previous year, painkillers over the previous 3 months, and the potential three-month prevalence of physical doping and or cognitive doping in this group were assessed via an anonymous questionnaire. The Randomised Response Technique (RRT) was implemented for sensitive questions regarding “prescription drugs [ ... ] for the purpose of performance enhancement [ ... ] only available at a pharmacy or on the black market”. The survey did not directly state the word “doping,” but included examples of substances that could later be classed as physical and or cognitive doping. The subjects were not required to detail what they were taking. Overall, 1953 completed questionnaires were received from3134 registered starters at six regional events - themselves involving 17 separate races - in 2017. Of the respondents, 31.8% and 11.3% admitted to the use of dietary supplements, and of painkillers during the previous three months, respectively. Potential physical doping and cognitive doping over the preceding year were reported by 7.0% (Confidence Interval CI: 4.2–9.8) and 9.4% (CI: 6.6–12.3) of triathletes. Gender, age, experience in endurance sports, and number of weekly triathlon training hours were linked to potential physical or cognitive doping. Given the potentially relevant side effects of painkiller use and physical and or cognitive doping, we recommend that educational and preventative measures for them be implemented within amateur triathlons

The Prevalence of Legal Performance-Enhancing Substance Use and Potential Cognitive and or Physical Doping in German Recreational Triathletes, Assessed via the Randomised Response Technique

This study investigated the use of performance-enhancing substances in recreational triathletes who were competing in German races at distances ranging from super-sprint to long-distance, as per the International Triathlon Union. The use of legal drugs and over-the-counter supplements over the previous year, painkillers over the previous 3 months, and the potential three-month prevalence of physical doping and or cognitive doping in this group were assessed via an anonymous questionnaire. The Randomised Response Technique (RRT) was implemented for sensitive questions regarding “prescription drugs […] for the purpose of performance enhancement […] only available at a pharmacy or on the black market”. The survey did not directly state the word “doping,” but included examples of substances that could later be classed as physical and or cognitive doping. The subjects were not required to detail what they were taking. Overall, 1953 completed questionnaires were received from 3134 registered starters at six regional events—themselves involving 17 separate races—in 2017. Of the respondents, 31.8% and 11.3% admitted to the use of dietary supplements, and of painkillers during the previous three months, respectively. Potential physical doping and cognitive doping over the preceding year were reported by 7.0% (Confidence Interval CI: 4.2–9.8) and 9.4% (CI: 6.6–12.3) of triathletes. Gender, age, experience in endurance sports, and number of weekly triathlon training hours were linked to potential physical or cognitive doping. Given the potentially relevant side effects of painkiller use and physical and or cognitive doping, we recommend that educational and preventative measures for them be implemented within amateur triathlons

Outcome study of real-time MR-guided cervical periradicular injection therapy in an open 1.0 Tesla MRI system

PURPOSE To evaluate the accuracy, safety, and efficacy of cervical nerve root injection therapy using magnetic resonance guidance in an open 1.0 T MRI system. METHODS Between September 2009 and April 2012, a total of 21 patients (9 men, 12 women; mean age 47.1 ± 11.1 years) underwent MR-guided cervical periradicular injection for cervical radicular pain in an open 1.0 T system. An interactive proton density-weighted turbo spin echo (PDw TSE) sequence was used for real-time guidance of the MR-compatible 20-gauge injection needle. Clinical outcome was evaluated on a verbal numeric rating scale (VNRS) before injection therapy (baseline) and at 1 week and 1, 3, and 6 months during follow-up. RESULTS All procedures were technically successful and there were no major complications. The mean preinterventional VNRS score was 7.42 and exhibited a statistically significant decrease (P < 0.001) at all follow-up time points: 3.86 ± 1.53 at 1 week, 3.21 ± 2.19 at 1 month, 2.58 ± 2.54 at 3 months, and 2.76 ± 2.63 at 6 months. At 6 months, 14.3 % of the patients reported complete resolution of radicular pain and 38.1 % each had either significant (4-8 VNRS score points) or mild (1-3 VNRS score points) relief of pain; 9.5 % experienced no pain relief. CONCLUSION Magnetic resonance fluoroscopy-guided periradicular cervical spine injection is an accurate, safe, and efficacious treatment option for patients with cervical radicular pain. The technique may be a promising alternative to fluoroscopy- or CT-guided injections of the cervical spine, especially in young patients and in patients requiring repeat injections

Value of routine transpedicular biopsies in kyphoplasty and vertebroplasty for vertebral compression fractures A survey among 250 spine surgeons

Background Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma. Objective To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures. Material and methods A web-based (UmfrageOnline (R)) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU). Results Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained. Discussion Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy

Evaluation of an Injectable Biphasic Calcium Sulfate/Hydroxyapatite Cement for the Augmentation of Fenestrated Pedicle Screws in Osteoporotic Vertebrae : A Biomechanical Cadaver Study

Cement augmentation of pedicle screws is one of the most promising approaches to enhance the anchoring of screws in the osteoporotic spine. To date, there is no ideal cement for pedicle screw augmentation. The purpose of this study was to investigate whether an injectable, bioactive, and degradable calcium sulfate/hydroxyapatite (CaS/HA) cement could increase the maximum pull-out force of pedicle screws in osteoporotic vertebrae. Herein, 17 osteoporotic thoracic and lumbar vertebrae were obtained from a single fresh-frozen human cadaver and instrumented with fenestrated pedicle screws. The right screw in each vertebra was augmented with CaS/HA cement and the un-augmented left side served as a paired control. The cement distribution, interdigitation ability, and cement leakage were evaluated using radiographs. Furthermore, pull-out testing was used to evaluate the immediate mechanical effect of CaS/HA augmentation on the pedicle screws. The CaS/HA cement presented good distribution and interdigitation ability without leakage into the spinal canal. Augmentation significantly enhanced the maximum pull-out force of the pedicle screw in which the augmented side was 39.0% higher than the pedicle-screw-alone side. Therefore, the novel biodegradable biphasic CaS/HA cement could be a promising material for pedicle screw augmentation in the osteoporotic spine

Identification of Metastamirs as Metastasis-associated MicroRNAs in Clear Cell Renal Cell Carcinomas

MicroRNAs (miRNAs) play a pivotal role in cancerogenesis and cancer progression, but their specific role in the metastasis of clear cell renal cell carcinomas (ccRCC) is still limited. Based on microRNA microarray analyses from normal and cancerous samples of ccRCC specimens and from bone metastases of ccRCC patients, we identified a set of 57 differentially expressed microRNAs between these three sample groups of ccRCC. A selected panel of 33 miRNAs was subsequently validated by RT-qPCR on total 57 samples. Then, 30 of the 33 examined miRNAs were confirmed to be deregulated. A stepwise down-regulation of miRNA expression from normal, over primary tumor to metastatic tissue samples, was found to be typical. A total of 23 miRNAs (miR-10b/-19a/-19b/-20a/-29a/-29b/-29c/-100/-101/-126/-127/-130/-141/-143/-145/-148a/-192/-194/-200c/-210/-215/-370/-514) were down-regulated in metastatic tissue samples compared with normal tissue. This down-regulated expression in metastatic tissue in comparison with primary tumor tissue was also present in 21 miRNAs. In cell culture experiments with 5-aza-2'-deoxycytidine and trichostatin A, epigenetic modifications were shown as one reason of this down-regulation. The altered miRNA profiles, comprising newly identified metastasis-associated miRNAs, termed metastamir and the predicted miRNA-target interactions together with the significant correlations of miRNAs that were either lost or newly appeared in the studied sample groups, afford a solid basis for further functional analyses of individual miRNAs in RCC metastatic progression.</p