Treatment of Metastatic Spinal Disease; what the Radiologist needs to know.

Advancements in technology and multidisciplinary management have revolutionized the treatment of spinal metastases. Imaging plays a pivotal role in determining the treatment course for spinal metastases. This article aims to review the relevant imaging findings in spinal metastases from the perspective of the treating clinician, describe the various treatment options, and discuss factors influencing choice for each available treatment option. Cases that once required radical surgical resection or low-dose conventional external beam radiation therapy, or both, are now being managed with separation surgery, spine stereotactic radiosurgery/stereotactic body radiation therapy, or both, with decreased morbidity, improved local control, and more durable pain control. The primary focus in determining treatment choice is now on tumor control outcomes, treatment-related morbidity, and quality of life.

A Comparison of CT-Guided Bone Biopsy and Fluoroscopic-Guided Disc Aspiration as Diagnostic Methods in the Management of Spondylodiscitis.

BACKGROUND AND PURPOSE: Percutaneous tissue biopsy is a key step in the diagnosis and management of spondylodiscitis, often utilizing CT-guided bone biopsy or fluoroscopic-guided disc aspirations. Our objective was to compare radiation exposure, procedure time, sedation requirement & yield between the two modalities. MATERIALS AND METHODS: 103 patients in 2 cohorts underwent fluoroscopic-guided disc aspirations (n = 47) or CTguided bone biopsy (n = 46) for diagnosis of spondylodiscitis. Patient and imaging data were gathered to ensure matched cohorts. Interventional and post-procedural data included radiation exposure, procedure time, complications, and microbiological details. Yield was calculated using MRI findings as the gold standard for infection. RESULTS: There were no significant differences between cohorts in demographics, symptom duration, or pre-procedure antibiotics use. CT-guided bone biopsy required more general anesthesia (26% vs 0%, P < 0.001), had longer radiation exposure time (60 ± 24s vs 2 ± 3s, P < 0.001), radiation dose (114.4 ± 71.6 mGy vs 70.4 ± 147.2 mGy), and procedure time (62 ± 14m vs 31 ± 23m, P < 0.001) than fluoroscopic-guided disc aspirations. There was no significant difference in yield (34% vs 32%, P = 0.661), and it was not affected by antibiotic use. CONCLUSIONS: Both modalities have similar utility in isolating causative organisms in suspected cases of spondylodiscitis. Our results suggest that increased radiation exposure, longer procedure time, and increased anesthesia use are relative disadvantages of CT-guided biopsy without an increase in yield. Controlled trials may be beneficial in determining the optimal choice in different scenarios.

Efficacy of an opioid-sparing analgesic protocol in pain control after less invasive cranial neurosurgery.

INTRODUCTION: Opioid overuse in postoperative patients is a worrisome trend, and potential alternatives exist which warrant investigation. Nonsteroidal anti-inflammatory drug use in treating postoperative cranial surgery pain has been hampered by concern for inadequate pain control and increased risk of hemorrhagic complications. A safe and effective alternative to opioid-based pain management is critical to improving postoperative care. OBJECTIVE: The objective of this retrospective study was to determine whether an NSAID-based opioid-sparing pain management protocol (OSP) is effective in analgesic control of less invasive cranial surgery patients at 6-, 12-, and 24-hour postoperatively. Secondary aims included investigating differences in hemorrhagic complications. METHODS: Five hundred sixty-six consecutive patients who underwent cranial surgery before and after implementation of the celecoxib-based OSP were eligible. Propensity score matching was used to match patients in each cohort. RESULTS: The opioid-sparing cohort had lower pain scores at 6 hours (3.45 vs 4.19, P = 0.036), 12 hours (3.21 vs 4.00, P = 0.006), and 24 hours (2.90 vs 3.59, P = 0.010). Rates of postoperative hemorrhage were not significantly different (5% intervention vs 8% control, P = 0.527). The opioid-sparing pain management protocol provided comparable or better pain control in the first 24 hours after less invasive cranial surgery. Hemorrhage rates did not change with the use of an NSAID-based OSP. CONCLUSION: An effective alternative to the current standard opioid-based pain management is feasible for less invasive cranial surgery. Determinations of hemorrhage risk and more complex cranial surgery will require larger prospective randomized trials.

Transforaminal lumbar interbody fusion using a novel minimally invasive expandable interbody cage: patient-reported outcomes and radiographic parameters.

OBJECTIVE: The goal of this study was to evaluate the clinical and radiographic outcomes of a novel multidirectional in situ expandable minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF) cage. METHODS: A retrospective analysis of 69 consecutive patients undergoing a 1- or 2-level MIS TLIF using an expandable cage was performed over a 2-year period. Standard MIS techniques with pedicle screw fixation were used in all cases. Upright lateral dynamic flexion/extension radiographs were reviewed prior to and at 1 year after surgery. Clinical metrics included numeric rating scale for back and leg pain, Oswestry Disability Index, and the SF-12 and VR-12 physical and mental health surveys. Radiographic parameters included anterior and posterior disc height, neuroforaminal height, spondylolisthesis, segmental lordosis, lumbar lordosis, and fusion rate. RESULTS: A total of 69 patients representing 75 operative levels met study inclusion criteria. The mean patient age at surgery was 63.4 ± 1.2 years, with a female predominance of 51%. The average radiographic and clinical follow-ups were 372 and 368 days, respectively. A total of 63 patients (91%) underwent 1-level surgery and 6 patients (9%) underwent 2-level surgery. Significant reductions of numeric rating scale scores for back and leg pain were observed-from 6.1 ± 0.7 to 2.5 ± 0.3 (p < 0.0001) and 4.9 ± 0.6 to 1.9 ± 0.2 (p < 0.0001), respectively. A similar reduction in Oswestry Disability Index from 38.0 ± 4.6 to 20.0 ± 2.3 (p < 0.0001) was noted. Likewise, SF-12 and VR-12 scores all showed statistically significant improvement from baseline (p < 0.001). The mean anterior and posterior disc heights improved from 8.7 ± 1.0 mm to 13.4 ± 1.5 mm (p = 0.0001) and 6.5 ± 0.8 mm to 9.6 ± 1.1 mm (p = 0.0001), respectively. Neuroforaminal height improved from 17.6 ± 2.0 mm to 21.9 ± 2.5 mm (p = 0.0001). When present, spondylolisthesis was, on average, reduced from 4.3 ± 0.5 mm to 1.9 ± 0.2 mm (p = 0.0001). Lumbar lordosis improved from 47.8° ± 5.5° to 58.5° ± 6.8° (p = 0.2687), and no significant change in segmental lordosis was observed. The overall rate of radiographic fusion was 93.3% at 1 year. No perioperative complications requiring operative revision were encountered. CONCLUSIONS: In this series of MIS TLIFs, use of this novel interbody cage was shown to be safe and effective. Significant improvements in pain and disability were observed. Effective and durable restoration of disc height and neuroforaminal height and reduction of spondylolisthesis were obtained, with concurrent gains in lumbar lordosis. Taken together, this device offers excellent clinical and radiographic outcomes via an MIS approach.

Implementation of early follow-up care after heart failure hospitalization.

OBJECTIVES: The evidence supporting early postdischarge hospital follow-up is limited. We implemented a new, multidisciplinary, multistrategy heart failure (HF) team approach that included new clinic slots, predischarge nurse visit, providing a blood pressure cuff and scale, and cardiologist supervision. STUDY DESIGN: Pre- vs postintervention evaluation of outcomes in patients hospitalized with HF between September 1, 2010, and May 30, 2013. We utilized the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to evaluate the intervention. METHODS: For the quantitative evaluation, we compared the proportion of patients in both groups who were scheduled for and completed a cardiology appointment within 7 days after hospitalization ("reach"). We created a Cox model to evaluate the "effectiveness" of the intervention period on a 30-day composite outcome (all-cause emergency department [ED] visit, all-cause hospitalization, or death). In qualitative evaluation, we describe the adoption, implementation, and maintenance of the intervention. RESULTS: Data for 261 patients were analyzed (preintervention, n = 142; post intervention, n = 119). The postintervention period was associated with a higher proportion of patients who were referred to (40% vs 12%; P < .001) and completed (24% vs 10%; P = .003) cardiology follow-up within 7 days of hospital discharge (reach) compared with the preintervention period. After adjustment, the postintervention period was associated with a reduced hazard of the 30-day composite end point (HR, 0.59; 95% CI, 0.37-0.96; P = .04) (effectiveness). CONCLUSIONS: The intervention succeeded in increasing referral to and completion of cardiology appointments within 7 days of discharge. In adjusted analysis, the intervention was associated with lower risk of 30-day all-cause ED visits, all-cause hospitalizations, or death.

Surgical Treatments of Epilepsy.

Nearly 30% of epilepsy patients are refractory to medical therapy. Surgical management of epilepsy is an increasingly viable option for these patients. Although surgery has historically been used as a palliative option, improvements in technology and outcomes show its potential in certain subsets of patients. This article reviews the two main categories of surgical epilepsy treatment-resective surgery and neuromodulation. Resective surgery includes temporal lobe resections, extratemporal resections, laser interstitial thermal therapy, and disconnection procedures. We discuss the three main types of neuromodulation-vagal nerve stimulation, responsive neurostimulation, and deep brain stimulation for epilepsy. The history and indications are explored for each type of treatment. Given the myriad types of resection and neuromodulation techniques, patient selection is reviewed in detail, with a discussion on which patients are most likely to benefit from different treatment strategies. We also discuss outcomes with examples of the pertinent landmark trials and their results. Finally, complications and surgical technique are reviewed. As new indications emerge and patient selection is refined, surgical management will continue to evolve as an adjuvant therapy for epileptic patients.

Pediatric Brainstem Gliomas: A Retrospective Study of 180 Patients from the SEER Database.

BACKGROUND/AIMS: Large population-based studies are needed to assess the epidemiology and survival risk factors associated with pediatric brainstem gliomas. This retrospective study explores factors that may influence survival in this population. METHODS: Utilizing the SEER database, the authors retrospectively assessed survival in histologically confirmed brainstem gliomas in patients aged 17 and younger. Survival was described with Kaplan-Meyer curves and multivariate regression analysis. RESULTS: This analysis of 180 cases showed that age (hazard ratio [HR] 1.04, 95% CI 0.96-1.14, p = 0.34), non-white race (HR 1.00, 95% CI 0.35-2.85 p > 0.99), distant or invasive extension of the tumor (HR 0.4, 95% CI 0.08-2.53, p = 0.37), and radiation therapy (HR 1.27, 95% CI 0.52-3.11, p = 0.61) were not associated with decreased survival. High-grade tumor status (HR 8.64, 95% CI 3.49-21.41, p < 0.001) was associated with decreased survival. Partial resection (HR 0.11, 95% CI 0.04-0.30, p < 0.001) and gross-total resection (HR 0.03, 95% CI 0.01-0.14, p < 0.001) were associated with improved survival. CONCLUSIONS: High-grade brainstem gliomas have a worse prognosis. Early diagnosis and surgery appear to be associated with improved survival, while the role of radiation is unclear.

Retraction: Limited post-operative dexamethasone use does not affect lumbar fusion: a single institutional experience.

[This retracts the article DOI: 10.21037/jss.2018.05.20.].

Limited post-operative dexamethasone use does not affect lumbar fusion: a single institutional experience.

BACKGROUND: The use of exogenous dexamethasone during and after lumbar spine surgery remains controversial. The preponderance of studies on this topic is primarily from animal models and little is known about the effects of exogenous dexamethasone use on fusion outcomes in human subjects undergoing lumbar arthrodesis. The aim of this study is to investigate the effect of limited exogenous dexamethasone use on bone fusion after instrumented lumbar arthrodesis. METHODS: Consecutive adult patients (18 years and older) undergoing one and two level lumbar decompression and fusion between January 2013 and December 2014 were reviewed. Patients were dichotomized into one of two groups (A & B) based on whether they received dexamethasone-Group (A) dexamethasone; and Group (B) no dexamethasone. Baseline characteristics, operative details, length of hospital stay, rates of wound infection, and fusion rates at 1 year were gathered by direct medical record review. All patients enrolled in this study were followed for a minimum of 12 months after surgery. RESULTS: One hundred sixty-five consecutive patients undergoing 1- and 2-level fusions were included in the study. Fifty eight patients received dexamethasone and 107 patients did not. The mean ± SD age was similar between both cohorts ("dexamethasone": 58.12±16.25 years vs. "no dexamethasone": 61.00±12.95, P=0.24). The was no difference in the prevalence of smoking (P=0.72) between both cohorts. Length of in-hospital stay was similar between cohorts ("dexamethasone": 4.08±3.44 days vs. "no dexamethasone": 4.50±2.85 days, P=0.43). The incidence of post-operative infections was similar between cohorts. At 12 months after surgery, 70% of patients in the dexamethasone cohort had radiographic evidence of bony fusion compared to 73% of patients in the no-dexamethasone cohort (P=0.68). CONCLUSIONS: Our study suggests that a limited exposure to exogenous dexamethasone after lumbar spine fusion may not be associated with a lower fusion rate. Prospective randomized control trials are needed to corroborate our findings.

Implementation of a Postoperative Outpatient Care Pathway for Delayed Hyponatremia Following Transsphenoidal Surgery.

BACKGROUND: After transsphenoidal surgery, delayed hyponatremia (DH) is the leading cause of 30-d unplanned hospital readmissions. OBJECTIVE: To determine the impact of a DH care pathway on 30-d readmissions after transsphenoidal surgery. METHODS: Data from before and after DH care pathway implementation were retrospectively reviewed. Patient demographics and clinical characteristics were compared. Readmission causes, clinical pathway failures, sodium trends, and symptoms were evaluated. RESULTS: Before the DH care pathway implementation, 229 (55%) patients were treated (group 1); afterward, 188 (45%) were treated (group 2). Baseline characteristics were equivalent between groups, except for glucocorticoid supplementation, which was higher in group 2. The incidence of detected DH was significantly lower in group 1 (16/229, 7%) than group 2 (29/188, 15%) (P = .006) likely due to the impact of routine screening in group 2. Ten group 1 patients (4%) were readmitted for hyponatremia and 6 (3%) were managed as outpatients. Eleven group 2 patients (6%) were readmitted and 17 (9%) were managed as outpatients. Readmission rates between groups were similar (P = .49). Patients readmitted with severe hyponatremia experienced symptoms ≥24 h before presentation. The protocol failed to prevent readmission because outpatient management for mild or moderate DH (n = 4) failed, sodium levels precipitously declined after normal screening (n = 3), and severe hyponatremia developed after scheduled screenings were missed (n = 3). CONCLUSION: Although more DH patients were identified after care pathway implementation, readmission rates were not reduced and clinical outcomes were not changed. Because DH onset timing varies, some patients have highly acute presentation, and most readmitted patients develop symptoms before reaching their sodium nadir, close symptom monitoring may be a reasonable alternative to routine screening.