Characteristics of Patients Who Survived < 3 Months or > 2 Years After Surgery for Spinal Metastases: Can We Avoid Inappropriate Patient Selection?

PURPOSE: Survival after metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with pathologic spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve quality of life. Surgery is generally considered to be inappropriate if anticipated survival is < 3 months. The aim of this international multicenter study was to analyze data from patients who died within 3 months or 2 years after surgery, to identify preoperative factors associated with poor or good survival, and to avoid inappropriate selection of patients for surgery in the future. PATIENTS AND METHODS: A total of 1,266 patients underwent surgery for impending pathologic fractures and/or neurologic deficits and were prospectively observed. Data collected included tumor characteristics, preoperative fitness (American Society of Anesthesiologists advisory [ASA]), neurologic status (Frankel scale), performance (Karnofsky performance score [KPS]), and quality of life (EuroQol five-dimensions questionnaire [EQ-5D]). Outcomes were survival at 3 months and 2 years postsurgery. Univariable and multivariable logistic regression analyses were used to find preoperative factors associated with short-term and long-term survival. RESULTS: In univariable analysis, age, emergency surgery, KPS, EQ-5D, ASA, Frankel, and Tokuhashi/Tomita scores were significantly associated with short survival. In multivariable analysis, KPS and age were significantly associated with short survival (odds ratio [OR], 1.36; 95% CI, 1.15 to 1.62; and OR, 1.14; 95% CI, 1.02 to 1.27, respectively). Associated with longer survival in univariable analysis were age, number of levels included in surgery, KPS, EQ-5D, Frankel, and Tokuhashi/Tomita scores. In multivariable analysis, the number of levels included in surgery (OR, 1.21; 95% CI, 1.06 to 1.38) and primary tumor type were significantly associated with longer survival. CONCLUSION: Poor performance status at presentation is the strongest indicator of poor short-term survival, whereas low disease load and favorable tumor histology are associated with longer-term survival

Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Because previous studies have suggested that motorized non-surgical spinal decompression can reduce chronic low back pain (LBP) due to disc degeneration (discogenic low back pain) and disc herniation, it has accordingly been hypothesized that the reduction of pressure on affected discs will facilitate their regeneration. The goal of this study was to determine if changes in LBP, as measured on a verbal rating scale, before and after a 6-week treatment period with non-surgical spinal decompression, correlate with changes in lumbar disc height, as measured on computed tomography (CT) scans.</p> <p>Methods</p> <p>A retrospective cohort study of adults with chronic LBP attributed to disc herniation and/or discogenic LBP who underwent a 6-week treatment protocol of motorized non-surgical spinal decompression via the DRX9000 with CT scans before and after treatment. The main outcomes were changes in pain as measured on a verbal rating scale from 0 to 10 during a flexion-extension range of motion evaluation and changes in disc height as measured on CT scans. Paired t-test or linear regression was used as appropriate with p < 0.05 considered to be statistically significant.</p> <p>Results</p> <p>We identified 30 patients with lumbar disc herniation with an average age of 65 years, body mass index of 29 kg/m², 21 females and 9 males, and an average duration of LBP of 12.5 weeks. During treatment, low back pain decreased from 6.2 (SD 2.2) to 1.6 (2.3, p < 0.001) and disc height increased from 7.5 (1.7) mm to 8.8 (1.7) mm (p < 0.001). Increase in disc height and reduction in pain were significantly correlated (r = 0.36, p = 0.044).</p> <p>Conclusions</p> <p>Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height. A randomized controlled trial is needed to confirm these promising results.</p> <p>Clinical trial registration number</p> <p>NCT00828880</p

Long-Term Alterations of Cytokines and Growth Factors Expression in Irradiated Tissues and Relation with Histological Severity Scoring

PURPOSE: Beside its efficacy in cancer treatment, radiotherapy induces degeneration of healthy tissues within the irradiated area. The aim of this study was to analyze the variations of proinflammatory (IL-1α, IL-2, IL-6, TNF-α, IFN-γ), profibrotic (TGF-β1), proangiogneic (VEGF) and stem cell mobilizing (GM-CSF) cytokines and growth factors in an animal model of radiation-induced tissue degeneration. MATERIALS AND METHODS: 24 rats were irradiated unilaterally on the hindlimb at a monodose of 30 Gy. Six weeks (n=8), 6 months (n=8) and 1 year (n=8) after irradiation the mediators expression in skin and muscle were analyzed using Western blot and the Bio-Plex® protein array (BPA) technology. Additional histological severity for fibrosis, inflammation, vascularity and cellularity alterations scoring was defined from histology and immnunohistochemistry analyses. RESULTS: A significant increase of histological severity scoring was found in irradiated tissue. Skin tissues were more radio-sensitive than muscle. A high level of TGF-β1 expression was found throughout the study and a significant relation was evidenced between TGF-β1 expression and fibrosis scoring. Irradiated tissue showed a chronic inflammation (IL-2 and TNF-α significantly increased). Moreover a persistent expression of GM-CSF and VEGF was found in all irradiated tissues. The vascular score was related to TGF-β1 expression and the cellular alterations score was significantly related with the level of IL-2, VEGF and GM-CSF. CONCLUSION: The results achieved in the present study underline the complexity and multiplicity of radio-induced alterations of cytokine network. It offers many perspectives of development, for the comprehension of the mechanisms of late injuries or for the histological and molecular evaluation of the mode of action and the efficacy of rehabilitation techniques

Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty: A reappraisal of the vertebral venous system.

GesondheidswetenskappeAnatomie En HistologiePlease help us populate SUNScholar with the post print version of this article. It can be e-mailed to: [email protected]

Anatomical and pathological considerations in percutaneous vertebroplasty and kyphoplasty:A reappraisal of the vertebral venous system

Objectives. To focus attention of the clinician on the anatomy and (patho) physiology of the vertebral venous system, so as to offer a tool to better understand and anticipate ( potential) complications that are related to the application of percutaneous vertebroplasty and kyphoplasty. Background. Percutaneous vertebroplasty and kyphoplasty are newly developed, minimally invasive techniques for the relief of pain and for the strengthening of bone in vertebral body lesions. With the clinical implementation of these techniques, a number of serious neurologic and cardiopulmonary complications have been reported in the international medical literature. Most complications appear to be related to the extrusion of bone cement into the vertebral venous system. Methods. The literature about complications of percutaneous vertebroplasty and kyphoplasty is reviewed, and the anatomic and ( patho) physiologic characteristics of the vertebral venous system are reported. Based on what is currently known from the anatomy and physiology of the vertebral venous system, the procedures of percutaneous vertebroplasty and kyphoplasty are analyzed, and suggestions are made to improve the safety of these techniques. Conclusions. Thorough knowledge of the anatomic and ( patho) physiologic characteristics of the vertebral venous system is mandatory for all physicians that participate in percutaneous vertebroplasty and kyphoplasty. To reduce the risk of cement extrusion into the vertebral venous system during injection, vertebral venous pressure should be increased during surgery. This can be achieved by operating the patient in the prone position and by raising intrathoracic venous pressure with the aid of the anesthesiologist during intravertebral instrumentation and cement injection. Intensive theoretical and practical training, critical patient selection, and careful monitoring of the procedures, also taking into account patient positioning and intrathoracic and intra-abdominal pressures, will help to facilitate low morbidity outcomes in these very promising minimally invasive techniques

Resolving discogenic pain

Recent basic science studies on discogenic low back pain have provided new knowledge about this condition. This paper reviews some of these results and presents an overview of the following findings. The rat lumbar intervertebral disk may be innervated non-segmentally through the paravertebral sympathetic nerve and segmentally through the sinuvertebral nerves, and also by dichotomizing sensory fibers. The exposure of the nucleus pulposus (NP) to the outer annulus fibrosus (AF) may induce nerve injury and ingrowth into the disk. Nerve growth factor (NGF)-sensitive neurons are predominant in the rat intervertebral disk, which indicates that hyperalgesic responses can be induced by inflammation. NGF in the NP may promote axonal growth. Lumbar fusion may inhibit nerve ingrowth into the degenerated disk and reduce the percentage of calcitonin gene related peptide (CGRP)-positive neurons