Spinal clear cell meningiomas (CCMs) are a rare histological subtype of meningiomas that pose preoperative diagnostic challenges due to their radiographic similarities with other lesions. They are ...also more aggressive, exhibiting higher rates of recurrence, particularly in pediatric patients. Overcoming diagnostic challenges of these tumors can improve patient outcomes. In this report, we describe a case of a pediatric patient presenting with a lumbar CCM in whom we were able to obtain gross total resection. Our report reviews previously identified predictors of CCM recurrence, including the Ki-67 proliferation index, number of spinal segments involved, and hormonal influences related to age and sex. We describe the characteristic radiographic features that differentiate spinal CCMs from other tumors to improve pre-operative diagnosis. Furthermore, we provide our rationale for adjuvant therapy for pediatric patients to refine treatment protocols for these rare tumors.
To identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery.
The multicenter prospective American College of Surgeons National Quality ...Improvement Program database was queried for the years 2012–2016. Adult patients with disseminated cancer who underwent metastatic spinal tumor surgery were identified. Transfusion was defined as having received at least 1 intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used.
Of 1601 patients identified, 623 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher American Society of Anesthesiologists class (odds ratio OR = 1.54), preoperative anemia (OR = 3.10), instrumentation (OR = 1.63), and longer operative time (OR = 1.52). The overall complication rate was significantly higher in patients who received a transfusion compared with patients who did not receive a transfusion (22.3% vs. 15.0%, P < 0.001). Individual complications that were more common in patients who received a transfusion were sepsis (3.5% vs. 1.9%, P = 0.050), deep vein thrombosis (6.1% vs. 3.3%, P = 0.007), and prolonged ventilation (3.9% vs. 1.3%, P = 0.001). RBC transfusion (OR = 1.65), hypoalbuminemia (OR = 1.53), and anterior/anterolateral approaches for corpectomy (OR = 2.11) were independent risk factors for developing a postoperative complication.
RBC transfusion after metastatic spinal tumor surgery may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.
STUDY DESIGN.Retrospective cohort study.
OBJECTIVE.To evaluate a scoring system to predict morbidity for patients undergoing metastatic spinal tumor surgery (MSTS).
SUMMARY OF BACKGROUND ...DATA.Multiple scoring systems exist to predict survival for patients with spinal metastasis. The potential benefits and risks of surgery need to be evaluated for patients with disseminated cancer and limited life expectancy. Few scoring systems exist to predict perioperative morbidity after MSTS.
METHODS.We reviewed records of patients who underwent MSTS at our institution between 2013 and 2019. All perioperative complications occurring within 30 days were recorded. A clinical scoring system consisting of five variables (age ≥70, hypoalbuminemia, poor preoperative functional status (Karnofsky ≤40), Frankel Grade A-C, and multilevel disease (≥2 continuous vertebral bodies) was evaluated as a predictive tool for morbidity; every parameter was assigned a value of 0 if absent or 1 if present (total possible score = 5). The effect of the scoring system on morbidity was evaluated using stepwise multiple logistic regression. Model accuracy was calculated by receiver operating characteristic analysis.
RESULTS.One-hundred and five patients were identified, with a male prevalence of 58.1% and average age at surgery of 61 years. The overall 30-day complication rate was 36.2%. The perioperative morbidity was 4.6%, 30.0%, 53.9%, and 64.7% for patients with scores of 0, 1, 2, and ≥3 points, respectively (p < 0.001). On multiple logistic regression analysis controlling for covariates not present in the model, the scoring system was significantly associated with 30-day morbidity (OR 3.11; 95% CI, 1.72 – 5.59; p < 0.001). The modelʼs accuracy was estimated at 0.75.
CONCLUSION.Our proposed model was found to accurately predict perioperative morbidity after MSTS. The Spine Oncology Morbidity Assessment (SOMA) score may prove useful for risk stratification and possibly decision-making, though further validation is needed.Level of Evidence4
Retrospective single-institution study.
To determine the relationship between patients' insurance status and the likelihood for them to be recommended various spine interventions upon evaluation in ...our neurosurgical clinics.
Socioeconomically disadvantaged populations have worse outcomes after spine surgery. No studies have looked at the differential rates of recommendation for surgery for patients presenting to spine surgeons based on socioeconomic status.
We studied patients initially seeking spine care from spine-fellowship trained neurosurgeons at our institution from July 1, 2018 to June 30, 2019. Multivariable logistic regression was used to assess the association between insurance status and the recommended patient treatment.
Overall, 663 consecutive outpatients met inclusion criteria. Univariate analysis revealed a statistically significant association between insurance status and treatment recommendations for surgery (p < 0.001). Multivariate logistic regression demonstrated that compared with private insurance, Medicare (odds ratio OR 3.54, 95% confidence interval CI 1.21 - 7.53, p = 0.001) and Medicaid patients (OR 2.46, 95% CI 1.21 - 5.17, p = 0.014) were more likely to be recommended for surgery. Uninsured patients did not receive recommendations for surgery at significantly different rates than patients with private insurance.
Medicare and Medicaid patients are more likely to be recommended for spine surgery when initially seeking spine care from a neurosurgeon. These findings may stem from a number of factors, including differential severity of the patient's condition at presentation, disparities in access to care, and differences in shared decision making between surgeons and patients.Level of Evidence: 3.
•Racial disparities affect patients with metastatic spine disease.•African-American patients are more likely to present with cord compression and paralysis.•African-American patients are less likely ...to receive surgical intervention.•African-American patients are more likely to develop a complication, prolonged length of stay, and non-routine discharge.
Race is an important determinant of cancer outcome. The purpose of this study was to identify disparities in clinical presentation, treatment use, and in-hospital outcomes of patients with spinal metastases.
The United States National Inpatient Sample database (2004–2014) was queried to identify patients with metastatic disease and cord compression (MSCC) or spinal pathological fracture. Clinical presentation, type of intervention, and in-hospital outcomes were compared between races/ethnicities. Multivariate logistic regression analyses were performed and adjusted for differences in patient age, sex, insurance status, income quartile, hospital teaching status and size, Charlson comorbidity index, smoking status, tumor type, and neurological status.
A total of 145,809 patients were identified – 74.8 % Caucasian, 14.1 % African-American, 7.9 % Hispanic, and 3.2 % Asian. Over one-third of patients (38.1 %) presented with MSCC; 35.7 % of Caucasians, 50.3 % of AAs, 41.1 % of Hispanics, and 39.8 % of Asians (p < 0.001). Paralysis affected 8.4 % of all patients; 7.4 % of Caucasians, 12.7 % of AAs, 10.5 % of Hispanics, and 10.0 % of Asians (p < 0.001). For patients with MSCC, multivariate analysis showed that AAs were less likely to undergo surgical intervention (OR 0.71; 95 % CI, 0.62 – 0.82; p < 0.001), significantly more likely to experience a complication (OR 1.25; 95 % CI, 1.12–1.40; p < 0.001), significantly more likely to experience prolonged length of stay (OR 1.22; 95 % CI, 1.08–1.36; p = 0.001), and significantly more likely to experience a non-routine discharge (OR 1.19; 95 % CI, 1.05–1.35; p = 0.007) compared to Caucasians.
Minority groups with spinal metastatic disease may be at a disadvantage compared to Caucasians, with significant disparities found in presenting characteristics, type of intervention, and in-hospital outcomes. Continued efforts to overcome these differences are needed.
•We describe a novel technique for intraoperative thoracic spine localization.•The technique utilizes an esophageal temperature probe.•This technique avoids errors from parallax and decreases ...fluoroscopy time.
Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip’s location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.
STUDY DESIGN.Case series.
OBJECTIVE.To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries.
SUMMARY OF BACKGROUND ...DATA.Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making.
METHODS.We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeonʼs initial proposed surgery for a patient with the conference attendees’ consensus decision on the best treatment and measured compliance rates with the groupʼs recommended treatment.
RESULTS.The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range IQR 1–4). Participating surgeons complied with the groupʼs recommendation in 96.5% of cases.
CONCLUSION.In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients.Level of Evidence4
Patients with metastatic disease to the cervical spine have historically had poor outcomes, with an average survival of 15 months. Every effort should be made to avoid complications of surgical ...intervention for stabilization and decompression.
We identified patients who had undergone anterior cervical corpectomy and fusion (ACCF) or posterior cervical laminectomy and fusion (PCLF) for metastatic disease of the cervical spine using the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2016. Patients meeting the inclusion criteria were subsequently propensity matched 1:1. We compared the overall complications, intensive care unit level complications, mortality, and return to the operating room between the 2 groups.
After identifying the patients who met the inclusion criteria and propensity matching, a cohort of 240 patients was included, with 120 (50%) in the ACCF group and 120 (50%) in the PCLF group. The patients in the ACCF group were more likely to have experienced any complication (odds ratio, 2.1; 95% confidence interval, 1.1–4.1; P = 0.026) but not severe complications or a return to the operating room (P = 0.406 and P = 0.450, respectively).
In the present study, we found that anterior surgical approaches (ACCF) for metastatic cervical spine disease resulted in a significantly greater rate of overall complications (2.1 times more) compared with PCLF in the first 30 days. Although more studies are required to further elucidate this relationship, the general belief that the anterior approach is better tolerated by patients might not apply to patients with metastatic tumors.
