The importance of timely treatment for quality of life and survival in patients with symptomatic spinal metastases

Purpose: A major challenge in metastatic spinal disease is timely identification of patients. Left untreated, spinal metastases may lead to gross mechanical instability and/or neurological deficits, often requiring extensive invasive surgical treatment. The aim of this cohort study was to assess the correlation between delayed treatment of patients with spinal metastases and functional performance, quality of life and survival. / Methods: All patients surgically treated for metastatic spinal disease at a tertiary care facility were included for analysis. Patients who underwent elective surgery were considered as timely treated, whereas patients requiring emergency surgery were considered to be treated in a delayed fashion. EQ-5D scores, KPS scores and mortality rates were compared between the two groups. / Results: A total of 317 patients (215 timely treated, 102 delayed) had survivorship data available and 202 patients (147 timely treated, 55 delayed) had clinical data available. Multivariate analyses showed delayed treatment was associated with lower EQ-5D and KPS scores and higher mortality rates, independent of confounders such as baseline EQ-5D/KPS scores, neurological status, tumor prognosis and patient age. / Conclusions: The results from the present study show delayed treatment of patients with symptomatic spinal metastases has both direct and indirect adverse consequences for functional performance status, quality of life and survival. Optimization of referral pattern may accelerate the time to surgical treatment, potentially leading to better quality of life and survival

Combined Anterior-Posterior Surgery Versus Posterior Surgery for Thoracolumbar Burst Fractures: A Systematic Review of the Literature

Abstract: Study Design: A systematic quantitative review of the literature. Objective: To compare combined anterior-posterior surgery versus posterior surgery for thoracolumbar fractures in order to identify better treatments. Summary of Background Data: Axial load of the anterior and middle column of the spine can lead to a burst fracture in the vertebral body. The management of thoracolumbar burst fractures remains controversial. The goals of operative treatment are fracture reduction, fixation and decompressing the neural canal. For this, different operative methods are developed, for instance, the posterior and the combined anterior-posterior approach. Recent systematic qualitative reviews comparing these methods are lacking. Methods: We conducted an electronic search of MEDLINE, EMBASE, LILACS and the Cochrane Central Register for Controlled Trials. Results: Five observational comparative studies and no randomized clinical trials comparing the combined anteriorposterior approach with the posterior approach were retrieved. The total enrollment of patients in these studies was 755 patients. The results were expressed as relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes with 95% confidence intervals (CI). Conclusions: A small significantly higher kyphotic correction and improvement of vertebral height (sagittal index) observed for the combined anterior-posterior group is cancelled out by more blood loss, longer operation time, longer hospital stay, higher costs and a possible higher intra- and postoperative complication rate requiring re-operation and the possibility of a worsened Hannover spine score. The surgeons’ choices regarding the operative approach are biased: worse cases tended to undergo the combined anterior-posterior approach

Patients with diffuse idiopathic skeletal hyperostosis have an increased burden of thoracic aortic calcifications

OBJECTIVES: DISH has been associated with increased coronary artery calcifications and incident ischaemic stroke. The formation of bone along the spine may share pathways with calcium deposition in the aorta. We hypothesized that patients with DISH have increased vascular calcifications. Therefore we aimed to investigate the presence and extent of DISH in relation to thoracic aortic calcification (TAC) severity. METHODS: This cross-sectional study included 4703 patients from the Second Manifestation of ARTerial disease cohort, consisting of patients with cardiovascular events or risk factors for cardiovascular disease. Chest radiographs were scored for DISH using the Resnick criteria. Different severities of TAC were scored arbitrarily from no TAC to mild, moderate or severe TAC. Using multivariate logistic regression, the associations between DISH and TAC were analysed with adjustments for age, sex, BMI, diabetes, smoking status, non-high-density lipoprotein cholesterol, cholesterol lowering drug usage, renal function and blood pressure. RESULTS: A total of 442 patients (9.4%) had evidence of DISH and 1789 (38%) patients had TAC. The prevalence of DISH increased from 6.6% in the no TAC group to 10.8% in the mild, 14.3% in the moderate and 17.1% in the severe TAC group. After adjustments, DISH was significantly associated with the presence of TAC [odds ratio (OR) 1.46 [95% CI 1.17, 1.82)]. In multinomial analyses, DISH was associated with moderate TAC [OR 1.43 (95% CI 1.06, 1.93)] and severe TAC [OR 1.67 (95% CI 1.19, 2.36)]. CONCLUSIONS: Subjects with DISH have increased TACs, providing further evidence that patients with DISH have an increased burden of vascular calcifications

Diffuse idiopathic skeletal hyperostosis is associated with incident stroke in patients with increased cardiovascular risk

OBJECTIVES: Earlier retrospective studies have suggested a relation between DISH and cardiovascular disease, including myocardial infarction. The present study assessed the association between DISH and incidence of cardiovascular events and mortality in patients with high cardiovascular risk. METHODS: In this prospective cohort study, we included 4624 patients (mean age 58.4 years, 69.6% male) from the Second Manifestations of ARTerial disease cohort. The main end point was major cardiovascular events (MACE: stroke, myocardial infarction and vascular death). Secondary endpoints included all-cause mortality and separate vascular events. Cause-specific proportional hazard models were used to evaluate the risk of DISH on all outcomes, and subdistribution hazard models were used to evaluate the effect of DISH on the cumulative incidence. All models were adjusted for age, sex, body mass index, blood pressure, diabetes, non-HDL cholesterol, packyears, renal function and C-reactive protein. RESULTS: DISH was present in 435 (9.4%) patients. After a median follow-up of 8.7 (IQR 5.0–12.0) years, 864 patients had died and 728 patients developed a MACE event. DISH was associated with an increased cumulative incidence of ischaemic stroke. After adjustment in cause-specific modelling, DISH remained significantly associated with ischaemic stroke (HR 1.55; 95% CI: 1.01, 2.38), but not with MACE (HR 0.99; 95% CI: 0.79, 1.24), myocardial infarction (HR 0.88; 95% CI: 0.59, 1.31), vascular death (HR 0.94; 95% CI: 0.68, 1.27) or all-cause mortality (HR 0.94; 95% CI: 0.77, 1.16). CONCLUSIONS: The presence of DISH is independently associated with an increased incidence and risk for ischaemic stroke, but not with MACE, myocardial infarction, vascular death or all-cause mortality

Definition of strategies for the reduction of operational inefficiencies in a stroke unit

Stroke disease is the second common cause of death in the world and is then of particular concern to policy-makers. Additionally, it is a meaningful problem leaving a high number of people with severe disabilities, placing a heavy burden on society and incurring prolonged length of stay. In this respect, it is necessary to develop analytic models providing information on care system behavior in order to detect potential operational inefficiencies along the stroke patient journey and subsequently design improvement strategies. However, modeling stroke care is highly complex due to the multiple clinical outcomes and different pathways. Therefore, this paper presents an integrated approach between Discrete-event Simulation (DES) and Markov models so that integrated planning of healthcare services relating to stroke care and the evaluation of potential improvement scenarios can be facilitated, made more logically robust and easy to understand. First, a stroke care system from Colombia was characterized by identifying the exogenous and endogenous variables of the process. Afterward, an input analysis was conducted to define the probability distributions of the aforementioned variables. Then, both DES and Markov models were designed and validated to provide deeper analysis of the entire patient journey. Finally, the possible adoption of thrombolytic treatment on patients with stroke disease was assessed based on the proposed approaches within this paper. The results evidenced that the length of stay (LOS) decreased by 12,89% and the mortality ratio was diminished by 21,52%. Evaluation of treatment cost per patient is also carried out

Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine

Oncological management of skeletal metastases has changed dramatically in the last few decades. A significant number of patients survive for many years with their metastases.Surgeons are more active and the technical repertoire is broader, from plates to intramedullary devices to (tumour) endoprostheses.The philosophy of treatment should be different in the case of a trauma-related fracture and a pathological fracture. A proper algorithm for establishing a diagnosis and evaluation of prognostic factors helps in planning the surgical intervention.The aim of palliative surgery is usually to eliminate pain and to allow the patient to regain his/her mobility as well as to improve the quality of life through minimally invasive techniques using life-long durable devices.In a selected group of patients with an oncologically controlled primary tumour site and a solitary bone metastasis with positive prognostic factors, which meet the criteria for radical excision (approximately 10% to 15% of the cases), a promising three to five years of survival may be achieved, especially in cases of metastases from breast and kidney cancer.Spinal metastases require meticulous evaluation because decisions on treatment mostly depend on the tumour type, segmental stability, the patient's symptoms and general state of health.Advanced radiotherapy combined with minimally invasive surgical techniques (minimally invasive stabilisation and separation surgery) provides durable local control with a low complication rate in a number of patients. Cite this article: EFORT Open Rev 2017;2:372-381

What should an ideal spinal injury classification system consist of? A methodological review and conceptual proposal for future classifications

Since Böhler published the first categorization of spinal injuries based on plain radiographic examinations in 1929, numerous classifications have been proposed. Despite all these efforts, however, only a few have been tested for reliability and validity. This methodological, conceptual review summarizes that a spinal injury classification system should be clinically relevant, reliable and accurate. The clinical relevance of a classification is directly related to its content validity. The ideal content of a spinal injury classification should only include injury characteristics of the vertebral column, is primarily based on the increasingly routinely performed CT imaging, and is clearly distinctive from severity scales and treatment algorithms. Clearly defined observation and conversion criteria are crucial determinants of classification systems’ reliability and accuracy. Ideally, two principle spinal injury characteristics should be easy to discern on diagnostic images: the specific location and morphology of the injured spinal structure. Given the current evidence and diagnostic imaging technology, descriptions of the mechanisms of injury and ligamentous injury should not be included in a spinal injury classification. The presence of concomitant neurologic deficits can be integrated in a spinal injury severity scale, which in turn can be considered in a spinal injury treatment algorithm. Ideally, a validation pathway of a spinal injury classification system should be completed prior to its clinical and scientific implementation. This review provides a methodological concept which might be considered prior to the synthesis of new or modified spinal injury classifications