Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study.

PURPOSE: Allogeneic blood transfusion (ABT) is current standard of blood replenishment despite known complications. Salvaged blood transfusion (SBT) addresses majority of such complications. Surgeons remain reluctant to employ SBT in metastatic spine tumour surgery (MSTS), despite ample laboratory evidence. This prompted us to conduct a prospective clinical study to ascertain safety of intraoperative cell salvage (IOCS), in MSTS. METHODS: Our prospective study included 73 patients who underwent MSTS from 2014 to 2017. Demographics, tumour histology and burden, clinical findings, modified Tokuhashi score, operative and blood transfusion (BT) details were recorded. Patients were divided based on BT type: no blood transfusion (NBT) and SBT/ABT. Primary outcomes assessed were overall survival (OS), and tumour progression was evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12 and 24 months, classifying patients with non-progressive and progressive disease. RESULTS: Seventy-three patients [39:34(M/F)] had mean age of 61 years. Overall median follow-up and survival were 26 and 12 months, respectively. All three groups were comparable for demographics and tumour characteristics. Overall median blood loss was 500 mL, and BT was 1000 mL. Twenty-six (35.6%) patients received SBT, 27 (37.0%) ABT and 20 (27.4%) NBT. Females had lower OS and higher risk of tumour progression. SBT had better OS and reduced risk of tumour progression than ABT group. Total blood loss was not associated with tumour progression. Infective complications other than SSI were significantly (p = 0.027) higher in ABT than NBT/SBT groups. CONCLUSIONS: Patients of SBT had OS and tumour progression better than ABT/NBT groups. This is the first prospective study to report of SBT in comparison with control groups in MSTS.

Analysis of unplanned hospital readmissions up to 2-years after metastatic spine tumour surgery.

PURPOSE: The aim of this study was to investigate rates, causes, and risk factors of unplanned hospital readmissions (UHR) within 30 days, 90 days, 1 year and 2 years after metastatic spine tumour surgery (MSTS) to augment multi-disciplinary treatment planning and improve patient education. METHODS: We retrospectively reviewed 272-patients who underwent MSTS between 2005 and 2016. Hospital records were utilised to obtain demographics, oncological, procedural details, and postoperative outcomes. All UHR within 2 years were reviewed. Primary outcomes were rates, causes, and risk factors of UHR. Risk factors for UHR were evaluated utilising multivariate logistic regression analysis. RESULTS: Thirty-day, 90 day, 1 year, and 2 year UHR-rates after MSTS were 17.2%, 31.1%, 46.2%, and 52.7%, respectively. Lung cancer primaries had the highest UHR-events (24.7%) whilst renal/thyroid displayed the least (6.6%). Disease-related causes (16.2%) were the most common reason for readmissions across all timeframes, followed by respiratory (13.7%) and progression of metastatic spine disease (12.7%). Urological conditions accounted for majority of readmissions within 30-days; disease-related causes, symptomatic spinal metastases, and respiratory conditions represented the most common causes at 30-90 days, 90 days-1 year, and 1-2 years, respectively. An ECOG >1 (p = 0.057), CCI >7 (p = 0.01), and primary lung tumour (p = 0.02) significantly increased UHR-risk on multivariate analysis. CONCLUSION: Seventy-four percent of patients had at least one UHR within 2 years of MSTS and majority were secondary to disease-related causes. Majority of first UHR occurred between 30 and 90 days post-surgery. Local disease progression and overall disease progression account for the highest UHR-events at 90 days-1 year and 1-2 year timeframes, respectively. We define UHR in specific timeframes, thus enabling better surveillance and reducing unnecessary morbidity.

Surgical Management of Multiple Myeloma With Symptomatic Involvement of the Spine.

INTRODUCTION: Multiple myeloma (MM) is the most frequent primary malignancy of the spine. We aimed to investigate the clinical presentation, surgical indications and outcomes, complications, survival, and its influencing factors in surgically treated MM patients with symptomatic involvement of the spine (SIS). METHODS: Retrospective analysis of prospectively collected data. Out of 350 MM patients treated at our institution over a period of 12 years (2006-2018), we identified 24 patients who were surgically treated for SIS. We collected data on demographics, clinical presentation, comorbidities, surgical indications, and outcomes and investigated the factors predisposing to postoperative complications and survival. RESULTS: The median follow-up duration was 85 months; median overall survival (OS) was 50 months. Clinical presentation at admission included pain (88%), sensory and/or motor deficit (67%), and bowel/bladder dysfunction (25%). Symptomatic pathological fractures were seen in 33%. Predominant surgical indications were rapid neurological deterioration with or without spinal cord compression (SCC), followed by mechanical instability. The majority of our patients benefited from surgery in terms of pain reduction in the short term as well as in the long term. There were 21% patients with surgical-related complications (<3 months). Surgical site infections occurred in 17%, without any obvious factors predisposing to infective complications. Neurological deterioration during hospital stay, especially in the presence of motor deficit and/or bowel/bladder dysfunction, significantly reduced OS. CONCLUSIONS: Sudden-onset neurological deterioration was the predominant factor leading to surgery. We achieved good short- and long-term pain reduction. Surgery is a valuable option for MM patients with SIS who present with rapid neurological deterioration with or without SCC and/or mechanical instability.

First Clinical Experience with a Carbon Fibre Reinforced PEEK Composite Plating System for Anterior Cervical Discectomy and Fusion.

Carbon fibre reinforced polyether ether ketone (CFR-PEEK) is a suitable material to replace metal implants in orthopaedic surgery. The radiolucency of CFR-PEEK allows an optimal visualisation of the bone and soft tissue structures. We aimed to assess the performance and radiological and clinical outcomes of anterior cervical discectomy and fusion (ACDF) with CFR-PEEK anterior cervical plating (ACP) under first use clinical conditions. We retrospectively studied the prospectively-collected data of 42 patients who underwent ACDF with CFR-PEEK ACP between 2011 and 2016. We assessed clinical outcome (Odom's criteria, complications) and radiological parameters (global and segmental cervical lordosis, Bridwell score for fusion, adjacent segment degeneration) preoperatively, immediately post-operatively, and after a 12-month follow-up period. Patients' satisfaction was excellent, good, fair, and poor in 12, 19, 3, and 1 patients, respectively. Two patients developed dysphagia. No hardware failure occurred. Compared with preoperative radiographs, we observed a gain of global cervical lordosis and segmental lordosis (7.4 ± 10.1 and 5.6 ± 7.1 degrees, respectively) at the 12-month follow-up. Bridwell IF grades I, II, and III were observed in 22, 6, and 7 patients, respectively. The 12-month adjacent segment degeneration-free and adjacent segment disease-free survival rates were 93.1% and 96.3%, respectively. We observed a dysphagia rate of 5.7% and a reoperation rate of 4.8%. In conclusion, CFR-PEEK ACP shows positive outcomes in terms of implant safety, restoration of cervical lordosis, and functional recovery, and is suitable for ACDF.

Intraoperative Neuromonitoring (IONM): Is There a Role in Metastatic Spine Tumor Surgery?

STUDY DESIGN: A retrospective design. OBJECTIVE: We aim to report our experience with multimodal intraoperative neuromonitoring (IONM) in metastatic spine tumor surgery (MSTS). SUMMARY OF BACKGROUND DATA: IONM is considered as standard of care in spinal deformity surgeries. However, limited data exist about its role in MSTS. METHODS: A total of 135 patients from 2010 to 2017, who underwent MSTS with IONM at our institute, were studied retrospectively. After excluding seven with no baseline signals, 128 patients were analyzed. The data collected comprised of demographics, pre and postoperative American Spinal Injury Association (ASIA) grades and neurological status, indications for surgery, type of surgical approach. Multimodal IONM included somatosensory-evoked potentials (SSEPs), transcranial electric motor-evoked potentials (tcMEP), and free running electromyography (EMG). RESULTS: The 128 patients included 61 males and 67 females with a mean age of 61 years. One hundred sixteen underwent posterior procedures; nine anterior and three both. The frequency of preoperative ASIA Grades were A = 0, B = 0, C = 10, D = 44, and E = 74 patients. In total, 54 underwent MSTS for neurological deficit, 66 for instability pain, and 8 for intractable pain.Of 128 patients, 13 (10.2%) had significant IONM alerts, representing true positives; 114 true negatives, one false negative, and no false positives. Among the 13 true positives, four (30%) underwent minimally invasive and nine (70%) open procedures. Eight (69.2%) patients had posterior approach. Seven (53.84%) true positive alerts were during decompression, which resolved to baseline upon completion of decompression, while five (38.46%) were during instrumentation, which recovered to baseline after adjusting/downsizing the instrumentation, and one (8.3%) during lateral approach, which reversed after changing the plane of dissection. Of the seven patients without baseline, five were ASIA-A and two were ASIA-C. The sensitivity, specificity, positive, and negative predictive values were 99.1%, 100%, 100%, and 92.9%, respectively. CONCLUSION: Multimodal IONM in MSTS helped in preventing postoperative neurological deficit in 9.4% of patients. Its high sensitivity and specificity to detect intraoperative neurological events envisage its use in ASIA-grade D/E patients requiring instrumented decompression. LEVEL OF EVIDENCE: 3.

Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery.

To review the current status of salvaged blood transfusion (SBT) in metastatic spine tumour surgery (MSTS), with regard to its safety and efficacy, contraindications, and adverse effects. We also aimed to establish that the safety and adverse event profile of SBT is comparable and at least equal to that of allogeneic blood transfusion. MEDLINE and Scopus were used to search for relevant articles, based on keywords such as "cancer surgery," "salvaged blood," and "circulating tumor cells." We found 159 articles, of which 55 were relevant; 20 of those were excluded because they used other blood conservation techniques in addition to cell salvage. Five articles were manually selected from reference lists. In total, 40 articles were reviewed. There is sufficient evidence of the clinical safety of using salvaged blood in oncological surgery. SBT decreases the risk of postoperative infections and tumour recurrence. However, there are some limitations regarding its clinical applications, as it cannot be employed in cases of sepsis. In this review, we established that earlier studies supported the use of salvaged blood from a cell saver in conjunction with a leukocyte depletion filter (LDF). Furthermore, we highlight the recent emergence of sufficient evidence supporting the use of intraoperative cell salvage without an LDF in MSTS.

Factors influencing extended hospital stay in patients undergoing metastatic spine tumour surgery and its impact on survival.

Metastatic spine tumour surgeries (MSTS) are indicated for preservation or restoration of neurological function, to provide mechanical stability and pain alleviation. The goal of MSTS is to improve the quality of life of the patients with spinal metastases and rarely for oncological control which is usually achieved by adjuvant therapies. Hence outcome measures such as length of stay (LOS) and rate of complications after MSTS are important indicators of quality but there is limited literature evidence for the same. We carried out a retrospective study to determine the incidence and the factors influencing normal (nLOS) and extended length of stay (eLOS) after MSTS. Data of 220 consecutive patients who underwent MSTS between 2005 and 2015 were retrieved from hospital electronic records. The preoperative, intraoperative and postoperative variables, discharge destinations as well as socioeconomic factors were analyzed. eLOS defined as positive when the LOS exceeded the 75th percentile for this cohort, was the key outcome indicator. Univariate and multivariate logistic regression analyses were performed to determine the predictive factors of eLOS. The overall median LOS was 7 days (1-30 days) and 55 patients had eLOS (LOS ≥ 11 days). Multivariate analysis revealed that significant variables independently associated with eLOS were instrumentation >9 spinal segmental levels (OR 2.89, 95% CI 1.1-7.5, p = 0.032) and presence of postoperative complications (OR 3.68, 95% CI 1.85-7.30, p < 0.001). Metastatic tumours other than breast, prostate and lung have lesser risk of eLOS (OR 0.31, 95% CI 0.14-0.70, p = 0.004). Survival estimates show that patients with eLOS have shorter survival than patients with nLOS (Crude HR 1.81, 95% CI 1.13-2.89, p = 0.003).