Surgical resection and reconstruction after resection of tumors involving the sacropelvic region

Objectives Surgical management of the tumors in the sacropelvic region is a challenging field of spine surgery because of the complex local anatomy and biomechanics. Recent development in anesthesia and intensive care has allowed us to perform extended surgeries focused on the en bloc resection of sacropelvic tumors. Various techniques for the resection and for the reconstruction were published in the last decade. Methods Sacropelvic tumor resection techniques and methods for the biomechanical and soft-tissue reconstruction are reviewed in this paper. Results Literature data is based on case reports and case-series. Several different techniques were developed for the lumbopelvic stabilization after sacropelvic tumor resection according to three different reconstruction principles (spinopelvic fixation, posterior pelvic ring fixation, anterior spinal column fixation); however, long term follow up data and comparative studies of the different techniques are still missing. Soft-tissue reconstruction can be performed according to an algorithm depending on the surgical approach, but relatively high complication rates are reported with all reconstruction strategies. The clinical outcome of such surgeries should ideally be evaluated in three dimensions; surgical-, oncological-, and functional outcomes. The last, and most important step of the presurgical planning procedure is a careful presentation of the surgical goals and risks to the patient, who must provide a fully informed consent before surgery can proceed. Discussion Sacropelvic tumors are rare conditions. In the last decade, growing evidence was published on resection and reconstruction techniques for these tumors; however, experience at most medical centers is limited by the low case-number. Formation of international expert groups and initiation of multicenter studies is strongly encouraged to produce a high level of evidence in this special field of spine surgery

Surgical treatment of primary malignant tumors of the sacrum

Objectives The objective of the authors was to provide an up-to-date review about the epidemiology, diagnosis and surgical management of the malignant primary sacral tumors. Methods A PubMed search was conducted using a combination of the following items: (("Spinal Neoplasms"[Mesh]) AND "Sacrum"[Mesh]) NOT ("Metastasis" OR "Metastases" OR "Benign"). The literature review and the author's own surgical experiences were used to assess the current treatment strategies of the malignant sacral tumors. Results Twenty case series were identified, which studies discuss in detail the surgical strategies, the postoperative complications, the functional and onclolgic outcome, the recurrence free and the disease specific survival of this rare patient category. Discussion Sacral tumors are rare pathologies. Their management generates a complex medical problem, as they usually are diagnosed in advanced stages with extended dimensions involving the sacral nerves and surrounding organs. The evaluation and complex treatment of these rare tumors require a multidisciplinary approach, optimally at institutions with comprehensive care and experience. Although conventional oncologic therapeutic methods should be used as neoadjuvant or adjuvant therapies in certain histological types, en bloc resection with wide surgical margins is essential for long-term local oncologic control. This is often technically difficult to achieve, as just a few centers in the world perform sacral tumor surgeries on a regular basis, and have enough wide experience. Therefore international cooperation and organization of multicenter tumor registries are essential to develop evidence based treatment protocols

Primer Gerinctumor Regiszter az Országos Gerincgyógyászati Központban | Primary Spinal Tumor Registry in the National Centre for Spinal Disorders

A primer gerincdaganatok ritka betegségek. A gerincdaganat-regiszter kialakítása fontos információforrásként szerepelhet, elősegítheti a terápiás döntéshozatal tudományos megalapozását, növelve a gerincdaganatos betegek túlélési esélyeit. A szerzők bemutatják az Országos Gerincgyógyászati Központban működő Primer Gerinctumor Regisztert, amely egy modern adatbázis-kezelő szoftverre, a RedCap adatbázisra épül. A regiszter 18 év során összesen 323, primer gerincdaganattal diagnosztizált beteg adatát tartalmazza. 126 malignus daganat közül a leggyakrabban előforduló szövettani típus a chordoma volt (61 eset), míg a benignus daganatok közül a schwannoma prevalenciája volt a legmagasabb (45 eset). A regiszter adatait számos aspektusból elemezték. A szerzők rámutatnak arra, hogy a primer gerincdaganatok biológiai viselkedésének és terápiás lehetőségeinek vizsgálata csak akkor lehetséges, ha nagyszámú betegről szisztematikus adatgyűjtés történik. Az Országos Gerincgyógyászati Központban létrehozott Primer Gerincdaganat Regiszter felépítése lehetővé teszi a gyors, felhasználóbarát adatbevitelt, optimális adatbázist biztosítva a betegek utánkövetéséhez és a betegség tudományos kutatásához. Orv. Hetil., 2014, 155(19), 745–749. | Primary spinal tumors are rare diseases. Primary spinal tumor registry would be useful to help decision making in this complex field of spine surgery. In this article the authors present the latest findings from the Primary Spinal Tumor Registry at the National Centre for Spinal Disorders, Hungary. The registry is based on a novel database management software, the REDCap electronic data capture system. It contains data of 323 patients treated surgically during an 18-year period. Among the 126 malignant tumors, the most frequent was chordoma (61 cases). In the case of benign tumors schwannoma showed the largest prevalence (45 cases). The authors conclude that due to the rarity of the disease and the complexity of the management, multicenter, prospective registries are required to provide high level of evidence. The structure of the Primary Spinal Tumor Registry in the National Centre for Spinal Disorders in Hungary is optimal for user-friendly, fast and secure data collection providing a prospective database for scientific researches and clinical follow-up. Orv. Hetil., 2014, 155(19), 745–749

Attitude of spine surgeons towards the application of 3D technologies - a survey of AOSpine members

3D technologies (3D virtual and physical model, 3D printing, computer aided engineering, finite element analysis based simulations) play an important role in personalized spine surgery. Objective - In collaboration with AOSpine a global, online survey-based study was performed in order to determine the acceptance rate and the factors which stand against the wider spread of 3D technologies.A survey containing 21 questions was developed and divided into five pages, every page corresponding to one chapter. Our analysis is based on the responses of 282 spine surgeons from 57 countries. To interpret our results in a global context, we used the Human Development Index of the respondent's countries in comparisons.Significant difference between the AOSpine regions (p ≤ 0.05) was found, with the highest acceptance in Asia-Pacific region. There was no significant difference in acceptance score according to the field of spine surgery, or the surgical experience in years (p=0.77, and p=0.19). In the case of public practice, we found significantly higher acceptance compared to private and mixed (public and private) surgical practice (p ≤ 0.05). The acceptance of the technology varied based on the respondent's resident country's Human Development Index and was significantly different between "Medium" vs "Very high" (p = 0.0005) and "High" vs "Very high" (p=0.019) category. Significant positive correlation was found between the acceptance score and the HDI score (Spearman test, ρ = 0.37, p = 0.007). The main limitation factor was identified as the lack of information.There is high interest among spine surgeons towards the incorporation of 3D technologies into the clinical practice. Education, the healthcare system, and the economic environment plays a major role in acceptance. Our results provide the basis of a strategy to promote the application of 3D technologies. ---------------- [Bevezetés - A 3D technológiák (háromdimenziós virtuális és fizikai modellek, háromdimenziós nyomtatás, mérnöki digitális tervezés, végeselem-analízisre épülő szimuláció) kulcsszerepet játszanak az egyénre szabott gerincsebészeti beavatkozások megvalósításában. Célkitűzés - A 3D technológiák klinikai alkalmazását elősegítő és limitáló tényezők meghatározása érdekében nemzetközi, online felmérést végeztünk az AOSpine közreműködésével. Módszer - Kifejlesztettünk egy 21 kérdésből álló kérdőívet. A vizsgálat során 57 ország 282 gerincsebésze által kitöltött kérdőíveket használtunk fel. A kérdőívek számszerűsítve mérték az elfogódottságot különböző paraméterek mellett. Az adatok értékelésében a válaszadók származási országainak megfelelő humán fejlettségi indexet is figyelembe vettük. Eredmények - A 3D technológiák elfogadottsága az AOSpine-régiók között szignifikánsan eltért (p ≤ 0,05), a legnagyobb elfogadottságot az Ázsia/Csendes-óceáni régió mutatta. A gerincsebészeten belüli szakterület, illetve a gerincsebészként eltöltött évek szerint történő csoportosítás esetén nem találtunk szignifikáns különbséget (p = 0,77, illetve p = 0,19). A finanszírozást figyelembe véve, a 3D technológiák elfogadottsága szignifikánsan magasabb a kizárólag közfinanszírozott ellátásban dolgozó ge­rinc­sebészek esetén, a privát vagy mindkét (közfinanszírozott és privát) ellátáshoz viszonyítva (p ≤ 0,05). Az elfogadottság a humán fejlettségi index értéke alapján eltérő volt: szignifikáns különbséget találtunk a „Közepes” vs. „Nagyon magas” (p = 0,0005) és a „Magas” vs. „Nagyon magas” (p = 0,019) csoportba tartozó válaszadók közt; továbbá szignifikáns, pozitív korrelációt igazoltunk a technológia elfogadottsága és a humán fejlettségi index értéke közt (Spearman-teszt, ρ = 0,37, p = 0,007). A legfontosabb limitáló tényezőnek az ismerethiány bizonyult. Következtetés - Vizsgálatunk a 3D technológiák széles körű elfogadottságát bizonyítja. Az eredmény alátámasztja az oktatás, a gazdasági környezet, valamint a klinikai környezet/az egészségügy általános helyzetének szerepét. Vizsgálatunk alapul szolgálhat a 3D technológiák fejlesztésével és terjedésével kapcsolatos fő feladatok meghatározására.

Risk factors for surgical site infection in elective routine degenerative lumbar surgeries

BACKGROUND CONTEXT: Surgical site infection (SSI) is one of the most serious complications of spine surgery. Its predisposing factors, especially in routine surgeries, are less reported. However, a number of patient- and procedure-related risk factors could be avoided or at least determined preoperatively. Moreover, the patient-specific risk for SSI could be estimated before the elective surgery. PURPOSE: The aim of the present study was to analyze the preoperatively determinable risk factors for SSI in patients who require elective routine surgery related to lumbar disc degeneration and to build a multivariable model for the individual risk prediction. STUDY DESIGN: Analysis of prospectively collected standardized clinical data and the validation of the results on an independent prospective cohort were performed. PATIENT SAMPLE: One thousand thirty (N=1,030) patients were included in the study. All subjects underwent primary lumbar single- or two-level decompression, microdiscectomy, or instrumented fusion. OUTCOME MEASURES: Occurrence of an SSI defined according to the current Centers for Disease Control and Prevention guidelines that required surgical or nonsurgical therapy. METHODS: The effect of preoperative patient characteristics, comorbidities, disease history, and invasiveness of the elective surgery on the risk of SSI was determined in uni- and multivariate logistic regression models in the test cohort (N=723). The performance of the final multivariable regression model was assessed by measuring its discriminative ability (c-index) in receiver operating characteristic analysis. Performance of the multivariable risk estimation model was tested on the validation (N=307) cohort. RESULTS: The prevalence of SSI was 3.5% and 3.9% in the test and in the validation cohorts, respectively. The final multivariable regression model predictive (p=.003) for SSI contained the patient's age, body mass index (BMI), and the presence of 5 comorbidities, such as diabetes, ischemic heart disease, arrhythmia, chronic liver disease, and autoimmune disease as risk factors. The c-index of the model was 0.71, showing good discriminative ability, and it was confirmed by the data of the independent validation cohort (c=0.72). CONCLUSIONS: Predisposing factors for SSI were older age, higher BMI, and the presence of certain comorbidities in the present study. The cumulative number of risk factors significantly associated with the increasing risk for an SSI (p<.0001). Our model needs further validation but it may be used for individual risk assessment and reduction in the future

Complication Pattern After Percutaneous Cement Discoplasty: Identification of Factors Influencing Reoperation and Length of Hospital Stay

Objective Percutaneous cement discoplasty (PCD) was introduced to treat symptomatic vertical instability of the lumbar spine in a minimally invasive way. The aim of the present study was to analyze the complication pattern after PCD and to identify factors that predict the chance of cement leakage, reoperation, and length of hospital stay (LOS). Methods patients were treated with PCD within the study period. Clinical features and complications were analyzed by applying descriptive statistics, whereas perioperative factors predictive of cement leakage, reoperation, and LOS were identified by regression models. Results Cement leakage rate was 30.4% in the total cohort; however, only fifth of them were symptomatic. Cement leakage itself did not have a significant influence on clinical outcome. Other complications and nonsurgical adverse events were registered only in 2.0% of cases. Age, subcutaneous fat tissue thickness, low viscosity cement, lower level of surgeon's experience and the number of operated levels were identified as risk factors of cement leakage (P < 0.01; c-index = 0.836). Type of procedure, Charlson comorbidity score, reoperation, and nonsurgical adverse events significantly increased the LOS (P < 0.01). Cement leakage, early surgical practice, and increased subcutaneous fat tissue thickness were risk factors for reoperation (P < 0.01; c-index = 0.72). Conclusions PCD is a relatively safe and effective procedure for treating spinal instability caused by advanced-stage disc degeneration characterized by vacuum phenomenon. Cement leakage is not uncommon but is only a radiologic complication without clinical consequences in most cases. On the other hand, it can increase the LOS and is a significant risk factor for reoperation

Long-term outcomes in primary spinal osteochondroma: a multicenter study of 27 patients.

OBJECT Clinical outcomes in patients with primary spinal osteochondromas are limited to small series and sporadic case reports. The authors present data on the first long-term investigation of spinal osteochondroma cases. METHODS An international, multicenter ambispective study on primary spinal osteochondroma was performed. Patients were included if they were diagnosed with an osteochondroma of the spine and received surgical treatment between October 1996 and June 2012 with at least 1 follow-up. Perioperative prognostic variables, including patient age, tumor size, spinal level, and resection, were analyzed in reference to long-term local recurrence and survival. Tumor resections were compared using Enneking appropriate (EA) or Enneking inappropriate surgical margins. RESULTS Osteochondromas were diagnosed in 27 patients at an average age of 37 years. Twenty-two lesions were found in the mobile spine (cervical, thoracic, or lumbar) and 5 in the fixed spine (sacrum). Twenty-three cases (88%) were benign tumors (Enneking tumor Stages 1-3), whereas 3 (12%) exhibited malignant changes (Enneking tumor Stages IA-IIB). Sixteen patients (62%) underwent en bloc treatment-that is, wide or marginal resection-and 10 (38%) underwent intralesional resection. Twenty-four operations (92%) followed EA margins. No one received adjuvant therapy. Two patients (8%) experienced recurrences: one in the fixed spine and one in the mobile spine. Both recurrences occurred in latent Stage 1 tumors following en bloc resection. No osteochondroma-related deaths were observed. CONCLUSIONS In the present study, most patients underwent en bloc resection and were treated as EA cases. Both recurrences occurred in the Stage 1 tumor cohort. Therefore, although benign in character, osteochondromas still require careful management and thorough follow-up