The October 2023 Spine Roundup. 360. looks at: Cutting through surgical smoke: the science of cleaner air in spinal operations; Unlocking success: key factors in thoracic spine decompression and fusion for ossification of the posterior longitudinal ligament; Deep learning algorithm for identifying cervical cord compression due to degenerative canal stenosis on radiography; Surgeon experience influences robotics learning curve for minimally invasive lumbar fusion; Decision-making algorithm for the surgical treatment of degenerative lumbar spondylolisthesis of L4/L5; Response to preoperative steroid injections predicts surgical outcomes in patients undergoing fusion for isthmic spondylolisthesis

Introduction. Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre. Methods. Retrospective analysis of a prospectively collected database of 83 patients with unstable myelomatous lesions of the spine, defined by a Spinal Instability Neoplastic Score (SINS) of 13–18. Data collected include patient demographics, systemic treatment, neurological status, radiological presence of cord compression, most unstable vertebral level and presence of intraosseous and extraosseous bone formation. Post-treatment scores were calculated based on follow-up imaging which was carried out at 2 weeks for cord compression and 12 weeks for spinal instability. A paired t-test was used to identify any significant difference between pre- and post-treatment SINS and linear regression was used to assess the association between variables and the change in SINS. Results. A significant reduction in SINS was observed from a pre-treatment average score of 14 to a score of 9, following treatment for myeloma (p<0.001). A higher initial score and a younger age were associated with a larger overall reduction in SINS (p<0.001 and p=0.02 respectively). No single variable (bisphosphates, chemotherapy, radiotherapy and steroids) had a significant association with SINS reduction. 25 (30%) patients had spinal cord compression, all of which showed radiological resolution of cord compression at 2 weeks. No patients developed neurological deterioration during treatment and all patients had an improvement in their pain scores. 64 (77%) patients had evidence of intraosseous and/or extraosseous bone formation on their follow-up scan. Conclusion. Non-operative management in the form of bracing and systemic therapy is a safe and effective treatment for spinal instability and spinal cord compression in myeloma. Treatment of unstable myelomatous lesions of the spine with or without cord compression should not follow traditional guidelines for MSCC. The decision to adopt a non-operative approach in this cohort of patients should ideally be made in a tertiary centre with expertise in multiple myeloma and in a multidisciplinary setting

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

Aim: To determine that the aetiology of cord compression in mucopolysaccharidoses (MPS) type VI. To illustrate the variability of this complication of mucopolysaccharidoses even within families. To report the youngest MPS VI patient yet described with spinal cord compression and to present the technique and results of spinal stabilisation. Method: The course, clinical findings and management of three patients with MPS VI and two with MPS IV were reviewed. Results: The patients with MPS VI demonstrated that the pathogenesis of spinal cord compression in this condition is complex, with elements of joint instability, bony disease and soft tissue compression. Two of the patients with MPS VI are siblings: the younger sibling was 30 months old when she required surgery. She is the youngest reported patient with this complication of MPS VI. The patients with MPS IV are presented to illustrate similarities and differences in the pathogenesis of the same problem in the two disorders. Results of cervical spine stabilisation were found to be satisfactory. Conclusions: In both MPS IV and MPS VI spinal cord compression may be multi-factorial. This complication of the mucopolysaccharidoses needs to be considered even when the patient is very young

Study Design: Retrospective outcome measurement study. Objective: To study the functional outcome of surgery for patients presenting with severe extradural spinal cord compression. Subjects: All patients who: 1) were surgically treated for spinal cord compression between January 2001 and December 2003, 2) presented with Frankel grade A, B or C, 3) had extradural spinal cord compression secondary to tumour or infection, and 4) were operated on by a single surgeon. Outcome: Pre- and post-operative functional assessment was made by medical staff, a physiotherapist or both, using the Frankel grading. Frankel grade at 3 months was taken as the end point, unless death had occurred before this time, in which case the best postoperative Frankel’s grade was used. Results: The records of 41 patients with spinal extradural tumour or infection were reviewed. Fourteen patients had Frankel grade A, B, or C. Four were female and 10 male. The median age of the group was 63.5 (range 36 to 73 years). Two had infection and 12 had tumour. The surgical objective was to decompress the neural elements and to restore and maintain the alignment of the vertebral column. One patient had multiple laminotomies alone. Ten had posterior decompression and fusion. Three had anterior and posterior decompression and fusion. Twelve immobile patients became mobile (Frankel grade D and E) and two remained unchanged. Complications were; two superficial wound infection treated with antibiotics, one deep-seated infection requiring open drainage and one extradural haematoma requiring evacuation. Conclusions: Appropriate spinal cord decompression and reconstruction of the spinal column has a very good chance of restoring spinal cord function despite the severity of the presenting neurological deficit

Background: It is common practice nowadays to treat patients with metastatic epidural spinal cord compression (MESCC) surgically. Extend and type of surgery should be in proper relation to the expected survival time of the patient. It is still difficult to predict patient’s survival time and several scoring systems are evaluated in literature. Purpose: To evaluate potential prognostic factors for survival after surgery of metastatic spinal cord compression. Material and Methods: In this retrospective study we included all patients who underwent surgery for MESCC in two hospitals in the Netherlands between 2001 and 2007 (n = 56). Medical records were studied for the origin of the primary tumor, the sex, the location of MESCC, the presence of other bone or visceral metastases, the Karnofsky score and the ASA score. Survival data were obtained by computing the time difference between the date of surgery and death. Patients were divided in three groups for the localization of the primary tumor; fast (n=21), moderate (n=19) and slow (n=13) growing tumors. The group of fast growing tumors contains lung cancer, moderate contains renal cancer and slow growing contains breast cancer. Furthermore, groups were made for the location of MESCC and groups were made for the Karnofsky score. Survival times were compared with log-rank tests or cox regression. Results: The overall median survival after surgery was 7,8 months, with a minimal follow-up time of nineteen months. The difference in survival time between the groups of primary tumors was highly significant (p < 0,001). Patients with fast growing tumors had a much shorter survival time (median 3,5 months) than patients with slow growing tumors (median 60 months), and moderate growing tumors (median 15 months). Patients with visceral metastases had a significant shorter survival time, compared to patients without visceral metastases (p = 0,01). The presence of other bone metastases however, was of no influence, as was the location of MESCC. Patients with a baseline Karnofsky score of 80% or higher had a significant longer survival time than patients with a score of 70% or lower (p=0,022). Sex and ASA score are not significantly associated with survival time. Conclusion: The type of the primary tumor seems to be strongly associated with survival time. Besides the type of the primary tumor, the presence of visceral metastases and Karnofksy score are predictors for the survival time after surgery as well. Reliable prediction of survival is mandatory, in that way adjustable surgical treatment can be established

Purpose: The average age of people suffering spinal cord injuries in many countries is shifting toward an older population, with a disproportionate number occurring in the spondylotic cervical spine. These injuries are typically due to low energy impacts, such as a fall from standing height. Since a stenotic spinal canal (a common feature of a spondylotic cervical spine) can cause myelopathy when the spine is flexed or extended, traumatic flexion or extension likely causes the injury during the low energy impact. However, this injury mechanism has not been observed experimentally. Method: To better understand this injury mechanism an in-vitro study, using six whole cervical porcine spines, was conducted. The following techniques were combined to directly observe spinal cord compression in a stenotic spine during physiologic and super-physiologic motion:. A radio-opaque surrogate cord, with material properties matched to in-vivo specimens, replaced the real spinal cord. Sagittal plane X-rays imaged the surrogate cord in the spine during testing. Varying levels of canal stenosis were simulated by a M8 machine cap screw that entered the canal from the anterior by drilling through the C5 vertebral body. Pure moment loading and a compressive follower load were used to replicate physiologic and super-physiologic motion. Results: Initial results show that a stenotic occlusion that removes all extra space in the canal in the neutral posture, without compressing the cord, can lead to spinal cord compression within physiologic ranges of flexion and extension. The spinal cord can also be compressed during slightly super-physiologic flexion and extension with only 25% canal occlusion. Physiologic loads and motions in the same spines did not cause cord compression when canal occlusion was 0%. Conclusion: These results support the hypothesis that cervical spinal canal stenosis increases the risk of spinal cord injury because spinal cord compression was observed during motions and loads that would be safe for a non-stenotic spine. These results are limited primarily due to the use of a porcine spine. However, this new stenosis model and experimental technique will be applied to in-vitro human spine specimens in future work

Acute myelopathy is a rare complication of Scheuermann's disease. Three patients are reported where spinal cord compression occurred at the apex of a kyphos. All were male, aged 14, 18 and 20 years, and each had a profound neurological defect associated with a short, sharp kyphos in the low thoracic region. Each patient underwent anterior decompression and all made an almost full recovery. It is deduced that factors which may influence the onset of cord compression include the angle of kyphosis, the number of segments involved, the rate of change of the angle, local anatomical variations, trauma, and possible secondary impairment of the vasculature of the cord

1. A case of cervical cord compression due to a congenital anomaly of the arch of the axis, treated successfully by decompressive laminectomy twenty-six years after the onset of symptoms, is described. 2. The significance of bony abnormalities of the cervical spine as a treatable cause of spastic tetraparesis is stressed

Aim. To assess whether oncologists are adhering to the NICE guidelines on MSCC. Methods and Results. All patients who received radiotherapy for metastatic spinal cord compression from 1. st. June 2009 – 1. st. June 2010 were identified. This information was then compared to the data collected via the MSCC Coordinator. The notes and radiological investigations were reviewed by the spinal consultant. 34 patients received radiotherapy for MSCC, 15 patients were not referred to the spinal team prior to radiotherapy. On reviewing each individual case 2 patients may have potentially benefited from surgical intervention. Conclusion. Many patients are still not referred for spinal opinion. The vast majority of these patients would not have been suitable for surgery, however, a small number may have potentially benefited

Background. It is common practice nowadays to treat patients with metastatic epidural spinal cord compression (MESCC) surgically. Extend and type of surgery should be in proper relation to the expected survival time of the patient. It is still difficult to predict patient's survival time and different scoring systems are used. Reliable prediction of survival is mandatory, in that way adjustable surgical treatment can be established. Aim. Evaluating potential prognostic factors for survival after surgery for MESCC. Methods. In this retrospective study we included 56 patients who underwent surgery for MESCC in two hospitals in the Netherlands between 2001 and 2007, Medical records were studied for the origin of the primary tumour, location of MESCC and the number of spots, presence of visceral or axial metastases, Karnofsky-score and ASA-score. Patients were grouped, according Tomita et al., for the localization of the primary tumour; fast (n=21), moderate (n=19) and slow (n=16) growing tumours. Survival times were compared with log-rank tests. Results. The overall median survival after surgery was 7, 8 months (range: 0-69, 95% IV: 3, 2-12,2). The origin of the primary tumour (p=0,001), presence of visceral metastases (p=0,017) and Karnofsky-score (p=0,033) were related to survival; other evaluated parameters were not. Patients within the fast group had a shorter median survival time (3, 5 months) than patients in the slow (32 months) and moderate group (15 months). Patients with visceral metastases survived shorter than patients without (5, 5 vs. 15 months). Patients with a baseline Karnofsky-score of 80% or higher had a longer survival time than patients with a lower score (11, 5 vs. 7, 8 months). Conclusion. The origin of the primary tumour seems to be strongly associated with survival time, as are the presence of visceral metastases and the Karnofksy-score. A prediction model of spinal metastases should include these factors

To describe the development of a system of referral, initial data acquisition and subsequent database recording and outcome reporting for metastatic spinal cord compression. Deficiencies in the literature identified by the NICE GDG for MSCC for research were compared with our original database and modifications made to ensure prospective collection of currently recognised and some proposed relevant factors. In addition modifications were made to ensure that all NICE implementation audit data and “target “ data are recorded and can be seamlessly transferred to necessary destinations. This generates standardised reports of the presentation, management and longitudinal interval outcomes including analogue pain scales, analgesic requirement, neurological function, Karnofsky performance indices, Euroquols, and ODIs. It includes pretreatment prognostic indices (updated 2005 Tokuhashi scores) relevant to treatment selection and scale of surgical intervention. Outcomes can be subclassified by type of intervention relative to clinical status at intervention. In house live assessment has revealed some reducing minor operational flaws and initial external assessment is current. A comprehensive information system and treatment guide for this increasing group has been developed and is evolving. Common adoption would facilitate earlier recognition and optimise treatment to diminish the high human and financial cost of MSCC. Currently networks are setting up NSSGs and for this process to be enhanced and to avoid costly duplication adoption of this system modified following peer review is suggested

A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue. This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression

Introduction. Metastatic Spinal Cord Compression (MSCC) is a well recognised complication of cancer and a surgical emergency. We present the results of a prospective audit of process focusing on the timing of intervention for these patients from presentation/diagnosis to surgery. Methods. Prospective audit of all patients referred to a tertiary spine unit over 6 months (April –September 2010). All data captured on an excel database. Results. During the study period, 36 patients were referred to our unit with suspected MSCC. Thirty patients (mean age 64.9 years (46-89)) had confirmed MSCC, and of these 25 underwent decompression/stabilisation surgery (vertebroplasty/kyphoplasty (4), declined operation/unfit (7)). The presenting symptoms in the MSCC group were pain and neurological deterioration (16), pain only (7) and progressive neurology (3). The mean duration of pain was 131 days (3 days-over 2 years), and neurological progression was 14 days (1-120 days; Frankel C (3), D (16), E (7)) Four patients were non-ambulatory and 3 had urinary incontinence. The tumour histologies were Prostate (6), Renal (4), Breast (4), Haematological (4), Lung (3), Unknown (1), Others (3). The time from presentation to surgery was 12.9 hours (160mins- 36 hours) if the MRI was organised in our unit. But, if all patients with MSCC were included, together with those referred from other hospitals, the mean time from radiological diagnosis (MRI) to surgery was 29 hours (range 160 mins- >76 hours). Conclusion. This audit of process over 6 months shows that if MSCC is suspected, then patients should be referred to a specialist centre with out of hours MRI provision and where definitive treatment can take place

The rate of Metastatic Spinal Cord Compression (MSCC) has been increasing over recent years with increased patient survival from improved cancer treatment. MSCC presents an increasing demand for spinal surgical resources. NICE guidance was issued in 2008 to improve diagnosis and management and to prevent unnecessary delays which may result in disability. The recent advances in management of cancers coupled with improved spinal surgical approaches have improved the outcome in MSCC. Early surgery has been shown to improve restoration of function. A recent systematic review found that surgery produced superior results to radiotherapy alone for the management of MSCC. However, the quality of evidence so far is mostly from observational studies. We would like to use Bluespier to create a database of MSCC patients referred to our tertiary centre. Our database would include all adult patients referred to the spinal surgical service with MSCC. Information recorded would be the diagnosis, time of onset and imaging, comorbidities, previous interventions, clinical findings, ASIA score, mobility status, sphincteric status, Karnofsky, Tokuhashi, Tomita and Bauer scores. These scores have been shown by numerous studies to have the best predictive value for outcome following MSCC. The SINS and Boriani MSCC protocols will be collected and externally validated. Time to surgery, operative data and intra operative complications will be recorded. PROMs will include the Oswestry / Neck disability index, VAS and SF36 scores. Post operative complications, morbidity and mortality will be collected and the details of any other therapy received. We would score the patients on admission and at 3 months, 6 months and one year post operatively (if survival allows). This will be done in out patients and via postal and telephone questionnaires. The database will flag the time intervals. This database will enable us to improve the quality of care given to patients with MSCC, provide evidence to highlight the importance of prompt referral and surgical intervention, audit our care against the standards set out by NICE and establish the risks, complications and outcomes of surgical intervention in this high risk group. It will be the first study to externally validate and compare several different scoring systems and protocols (above) in the same cohort. Finally, the data can be used to perform a costing analysis for the treatment of MSCC in the NHS

Study Purpose. To review systematically review literature on the early diagnosis of spinal metastases and prediction of spinal cord compression (SCC) due to spinal metastases. Methods and results. From 13 electronic bibliographic databases were searched we identified 2,425 potentially relevant articles of which 31 met the inclusion criteria. These were quality appraised. Seventeen studies reported retrospective data, 10 were prospective studies, and three were other study designs. There was one systematic review. There were no randomised controlled trials. There were approximately 7,900 participants in the included studies and 5,782 participants were analysed. The sample sizes ranged from 41 to 859. Cancers reported were: lung alone (n=3); prostate alone (n=6); breast alone (n=7); mixed cancers (n=13); and unclear (n=1). Ninety-three prognostic factors were identified as potentially significant in predicting risk of SCC or collapse. Many of the included studies provided limited information about patient population and selection criteria and they varied in methodological quality, rigour and transparency. Several studies with mixed case populations identified type of cancer (e.g. breast, lung or prostate cancer) as a significant factor in predicting SCC, but determining the risk differential is difficult because of residual bias in studies. Overall the quality of the research was poor. The only predictors identified for SCC were number of spinal metastases, duration of disease, total disease burden and immediate symptomatology of cord involvement. Conclusion. It is disappointing that no factors other than duration, disease burden, and immediate symptomatology predict SCC. Early appropriate identification remains a clinical challenge

1. Three patients with backache and spinal cord or cauda equina compression due to Paget's disease of the vertebrae are reported; all three were relieved by laminectomy.

2. One case is of particular interest because it is only the second one reported where compression was due to a single affected vertebra.

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC.

Retrospective analysis

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15.

Neurological outcome and survival

A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery.

The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%.

There was no difference in neurological outcome between the 3 groups.

There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score.

To assess whether the timing of surgery is an important factor in neurological outcome in patients with MSCC.

Retrospective review

All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups - those who underwent surgery within 24 hours (Group 1), those 24 hours to 48 hours (Group 2) and those greater than 48 hours (Group 3).

Neurological outcome (improvement in Frankel score), complication rate and survival were assessed in all groups.

A total of 109 patients with MSCC were operated on in our unit during this time. Mean age of patients was 61 years (range 7 - 86).

The number that had at least one grade of Frankel improvement was 21 /37 (57%) in group 1; 11/17 (65%) in group 2 and 20/49 (41%) in group 3, p=0.03.

When patients treated less than 24 hours were compared with those greater than 24 hours, the Frankel grade improvement approached significance (p=0.05).

When we compared those who had surgery within 48 hours and those greater than 48 hours, the Frankel grade improvement was highly significant (p=0.009).

There was no difference in survival or complications between the groups.

Our results suggest that early surgical treatment in patients with MSCC gives a better neurological outcome but has no influence on survival or complication rates.

We report 14 cases of symptomatic ossification of the posterior longitudinal ligament (OPLL) diagnosed in non-oriental men between 1978 and 1985. All 14 patients had incomplete spinal cord syndromes due to OPLL in the cervical spine and had been referred undiagnosed from other institutions. Twelve had severe myelopathy and seven were wheelchair-bound before OPLL was diagnosed, while six patients had had operations elsewhere for their neurological dysfunction. There was a close association between OPLL and diffuse idiopathic skeletal hyperostosis (Forestier's disease) on plain radiographs, seven patients having both disorders. Enhanced CT scans proved to be the best diagnostic method for the localisation of cord compression, and magnetic resonance imaging, used on four recent cases, provided the best visualisation of the extent of involvement in the sagittal plane. We aim to heighten awareness of OPLL in non-orientals, in whom the clinical features, histological characteristics, and radiographic patterns are very similar to those of oriental patients.