Association between Opioid Requirement and Overall Survival in Patients with Spinal Metastases.

Introduction: Clinical evidence shows that opioid administration in cancer patients is associated with shorter survival. This study explored the impact of opioid requirement on overall survival of patients with spinal metastases. We also evaluated the association between opioid requirement and tumor-related spinal instability. Methods: We retrospectively identified 428 patients who had been diagnosed with spinal metastases from February 2009 to May 2017. Those with an opioid prescription during the first 1 month after the diagnosis were included in this study. Patients given opioids were divided into two groups: the opioid requirement group [≥5 mg oral morphine equivalent (OME)/day] and the nonopioid group (<5 mg OME/day). Spinal instability due to metastases was evaluated using the Spinal Instability Neoplastic Score (SINS). Cox proportional hazards analysis was performed to evaluate the relationship between opioid use and overall survival. Results: The most frequent primary cancer site was the lung, in 159 patients (37%), followed by the breast in 75 (18%) and the prostate in 46 (11%). Multivariate analyses showed that patients who required ≥5 mg OME/day were approximately twofold more likely to die after a spinal metastases diagnosis than those who required <5 mg OME/day (hazard ratio 2.13; 95% confidence interval 1.69-2.67; p<0.001). The SINS was significantly higher in the opioid requirement group than those in the nonopioid group (p<0.001). Conclusions: For patients with spinal metastases, opioid requirement was associated with shorter survival, independently of known prognostic factors. The patients were also more likely to have tumor-related spinal instability than those in the nonopioid group.

Association between Age and Trunk Muscle Area and Density in Patients with Spinal Metastases.

STUDY DESIGN: A retrospective study. PURPOSE: This study aimed to evaluate the relationship between age and trunk muscle composition and between trunk muscle composition and overall survival in patients with spinal metastasis. OVERVIEW OF LITERATURE: A low skeletal muscle mass is associated with a poor overall survival in patients with cancer. However, no previous studies have evaluated the relative effects of age and disease on muscle mass and muscle quality in patients with advanced cancer. METHODS: This study included 539 patients diagnosed with spinal metastasis from February 2009 to July 2018. The patients were categorized into four groups based on age: <59, 60-69, 70-79, and ≥80 years. Differences in trunk muscle composition among age groups and among groups were classified on the basis of survival (< or >3 months after spinal metastasis diagnosis) were evaluated. RESULTS: In total, 515 patients (273 men, 242 women; mean age, 67.8 years) with complete medical records were included in the analysis. No significant differences were observed in the area of the psoas and paravertebral muscles among age groups in either sex. A significant trend toward a low muscle density with the increase in age was found for both sexes. Patients who survived less than 3 months had significantly smaller trunk muscle area than those who survived for more than 3 months in both sexes. CONCLUSIONS: The results suggest that the reduction in muscle density is associated with advanced age, whereas a decreased muscle area is associated with pathology. Additionally, a small trunk muscle area was associated with a short overall survival. Further studies are needed to elucidate the underlying mechanisms of age- versus cancer-related changes in the muscle area and their influence on overall survival.

Decreased muscle mass and strength affected spinal sagittal malalignment.

PURPOSE: Correction surgeries for spinal malalignment showed good clinical outcomes; however, there were concerns including increased invasiveness, complications, and impact on medico-economics. Ideally, an early intervention is needed. To better understand the patho-mechanism and natural course of spinal alignment, the effect of factors such as muscle mass and strength on spinal sagittal imbalance were determined in a multicenter cross-sectional study. METHODS: After excluding metal implant recipients, 1823 of 2551 patients (mean age: 69.2 ± 13.8 years; men 768, women 1055) were enrolled. Age, sex, past medical history (Charlson comorbidity index), body mass index (BMI), grip strength (GS), and trunk muscle mass (TM) were reviewed. Spinal sagittal imbalance was determined by the SRS-Schwab classification. Multiple comparison analysis among four groups (Normal, Mild, Moderate, Severe) and multinomial logistic regression analysis were performed. RESULTS: On multiple comparison analysis, with progressing spinal malalignment, age in both sexes tended to be higher; further, TM in women and GS in both sexes tended to be low. On multinomial logistic regression analysis, age and BMI were positively associated with spinal sagittal malalignment in Mild, Moderate, and Severe groups. TM in Moderate and Severe groups and GS in the Moderate group were negatively associated with spinal sagittal malalignment. CONCLUSION: Aging, obesity, low TM, and low GS are potential risk factors for spinal sagittal malalignment. Especially, low TM and low GS are potentially associated with more progressed spinal sagittal malalignment. Thus, early intervention for muscles, such as exercise therapy, is needed, while the spinal sagittal alignment is normal or mildly affected.

Prognostic value of psoas major muscle density in patients with breast cancer metastases to bone: a retrospective single-center cohort study.

OBJECTIVE: Although sarcopenia is associated with poor prognosis for cancer patients, the relationship between muscle quantity and quality, and prognosis of breast cancer patients with bone metastases is unclear. This study aims to evaluate the association of muscle parameters, muscle area and density, and overall survival (OS) from the diagnosis of bone metastases in breast cancer patients with bone metastases. METHODS: This study retrospectively investigated the prognostic value of muscle area and density in 90 women who were diagnosed with breast cancer with bone metastases between September 2005 and June 2018. We measured psoas major muscle and paravertebral muscle area and density on single axial computed tomography images at the L3 level and subgrouped the patients into higher or lower groups for each muscle measurement, using median values as cutoffs. We evaluated associations between OS and muscle parameters, using a Cox proportional hazards model adjusted by age and prognostic score for bone metastases (modified Katagiri score). RESULTS: Median OS among patients with lower psoas major muscle density (25 months) was significantly shorter than in the higher psoas major muscle density group (61 months; hazard ratio: 1.79, 95% confidence interval: 1.01-3.16, P = 0.045). However, muscle area and paravertebral muscle density were not associated with OS in this setting. CONCLUSION: Lower psoas major muscle density was a predictor of poor prognosis in patients with breast cancer metastases to bone. The association between psoas major muscle density and prognosis allows wider research into interventions that can prevent loss of muscle density.

Gender-specific analysis for the association between trunk muscle mass and spinal pathologies.

We investigated the relationship between trunk muscle mass and spinal pathologies by gender. This multicenter cross-sectional study included patients aged ≥ 30 years who visited a spinal outpatient clinic. Trunk and appendicular muscle mass were measured using bioelectrical impedance analysis. The Oswestry Disability Index (ODI), visual analog scale (VAS) score for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated to evaluate spinal pathology. The association between trunk muscle mass and these parameters was analyzed by gender using a non-linear regression model adjusted for patients' demographics. We investigated the association between age and trunk muscle mass. We included 781 men and 957 women. Trunk muscle mass differed significantly between men and women, although it decreased with age after age 70 in both genders. Lower trunk muscle mass was significantly associated with ODI, SVA, and EQ5D score deterioration in both genders; its association with VAS was significant only in men. Most parameters deteriorated when trunk muscle mass was < 26 kg in men and < 19 kg in women. Lower trunk muscle mass was associated with lumbar disability, spinal imbalance, and poor quality of life in both genders, with significant difference in muscle mass.

Relationship between number of radiological risk factors for delayed union after osteoporotic vertebral fracture and clinical outcomes.

This study demonstrated that number of three specific radiological risk factors (MR T2WI confined high-intensity pattern and diffuse low-intensity pattern, thoracolumbar vertebrae involvement, middle column injury) added prognostic information for delayed union, kyphotic deformity, and prolonged pain. PURPOSE: Delayed union after osteoporotic vertebral fracture (OVF) causes prolonged pain, QOL impairment, progression of collapse, kyphotic deformity, and neurologic impairment. Some specific radiological findings can be useful for predicting delayed union. We aimed to explore the prevalence and concomitance of various types of radiological risk factors for delayed union after osteoporotic vertebral fracture (OVF) and to assess the impact of risk factor number on clinical outcomes. METHODS: A total of 508 patients with fresh OVF from 25 institutes were evaluated. All patients were treated conservatively without surgical interventions. At the 6-month follow-up, the patients were classified into bone union and delayed union groups based on plain X-ray findings. We examined the presence and absence of three specific radiological risk factors (MR T2WI confined high-intensity pattern and diffuse low-intensity pattern, thoracolumbar vertebrae involvement, middle column injury) and analyzed clinical outcomes according to numbers of radiological risk factors. RESULTS: Delayed union was observed in 101 patients (19.9%) at the 6-month follow-up. The most common radiological risk factor was thoracolumbar vertebrae involvement (73.8%), followed by middle column injury (33.9%) and specific MRI findings (T2WI confined high-intensity pattern and diffuse low-intensity pattern) (29.7%). Overall, 85 (16.7%) patients had zero radiological risk factors, 212 (42.7%) had one, 137 (27.0%) had two, and 69 (13.6%) had three. When assessing the number of radiographic risk factors which included the MRI findings (the 3-risk factor method), the odds ratio for delayed union after acute OVF was 5.8 in the 2/3-risk factor group and 13.1 in the 3/3-risk factor group. Even when assessing the number of radiographic risk factors without MRI findings (2-risk factor method), the odds ratio was 3.2 in the 1/2-risk factor group and 10.2 in the 2/2-risk factor group. CONCLUSION: Number of radiological risk factors added prognostic information for delayed union, kyphotic deformity, and prolonged pain.

Impact of paravertebral muscle in thoracolumbar and lower lumbar regions on outcomes following osteoporotic vertebral fracture: a multicenter cohort study.

We investigated the effect of paravertebral muscle (PVM) on poor prognosis in osteoporotic vertebral fracture (OVF) and remaining lower back pain (LBP) in the thoracolumbar and lower lumbar regions. Additional OVF occurrence in the thoracolumbar and remaining LBP in the lumbar region was significantly related to PVM fat infiltration percentage. PURPOSE: Paravertebral muscle (PVM) is an important component of the spinal column. However, its role in the healing process after osteoporotic vertebral fracture (OVF) is unclear. This study aimed to clarify the effect of PVM in thoracolumbar and lower lumbar regions on OVF clinical and radiological outcomes. METHODS: This was a multicenter prospective cohort study from 2012 to 2015. Patients ≥ 65 years old who presented within 2 weeks after fracture onset were followed up for 6 months. PVM was measured at the upper edge of the L1 and L5 vertebral body in the magnetic resonance imaging (MRI) T2-axial position at registration. The cross-sectional area (CSA), relative CSA (rCSA), and fat infiltration percentage (FI%) were measured. Severe vertebral compression, delayed union, new OVF, and remaining low back pain (LBP) were analyzed. RESULTS: Among 153 patients who were followed up for 6 months, 117 with measurable PVM were analyzed. Their average age was 79.1 ± 7.2 years, and 94 were women (80.3%). There were 48 cases of severe vertebral compression, 21 delayed unions, 11 new OVF, and 27 remaining LBP. Among all poor prognoses, only the FI% of the PVM was significantly associated with new OVF (p = 0.047) in the thoracolumbar region and remaining LBP (p = 0.042) in the lumbar region. CONCLUSION: The occurrence of additional OVF in the thoracolumbar region and remaining LBP in the lumbar region was significantly related to the FI% of the PVM. Physicians should be aware that patients with such fatty degeneration shown in acute MRI may require stronger treatment.

Bow hunter's syndrome after cervical laminoplasty in a patient with rheumatoid arthritis with bony ankylosis in the cervical spine: a case report.

Bow hunter's syndrome, or rotational vertebral artery (VA) occlusion, refers to vertebrobasilar insufficiency due to mechanical occlusion of the VA. We present a case of surgical treatment for bow hunter's syndrome that occurred after cervical laminoplasty in a patient with rheumatoid arthritis with bony ankylosis of the facet joints. A 59-year-old female with rheumatoid arthritis experienced sudden incomplete left hemiplegia. Fifteen months earlier, the patient had undergone cervical decompression surgery between C3 and C7. MRI of the head showed cerebral infarction in the right VA area, while vertebral angiography with the head rotated to the right revealed that the right VA was occluded at the level of C3-C4. The patient was successfully treated via posterior cervical fusion from C2 to C7. Patients with rheumatoid arthritis have a potential risk of cervical bony ankyloses. Cervical laminoplasty for patients with cervical bony ankyloses can induce rotational VA occlusion due to spinal rotational instability.

Low paravertebral muscle mass in patients with bone metastases from lung cancer is associated with poor prognosis.

PURPOSE: Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients. METHODS: The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS: The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors. CONCLUSIONS: Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.

Characteristic radiological findings for revision surgery after balloon kyphoplasty.

Balloon kyphoplasty (BKP) sometimes fails to improve patients' outcomes, with revision surgery, using anterior or posterior reconstruction, being required. The purpose of this study was to investigate the radiological risk factors of failure after BKP in the treatment of osteoporotic vertebral fractures (OVFs). This case-control study included 105 patients treated with single BKP and 14 patients  who required revision BKP. We evaluated radiological findings differentiating both groups, using plain radiography and computed tomography, before BKP. Angular flexion-extension motion was significantly greater in the revision than BKP group. While the frequency of pedicle fracture and posterior wall injury was not different between the groups, a split type fracture was more frequent in the revision group. Split type fracture had the highest adjusted odds ratio (OR) for revision (16.5, p = 0.018). Angular motion ≥14° increased the risk for revision surgery by 6-fold (p = 0.013), with endplate deficit having an OR of revision of 5.0 (p = 0.032). The revision rate after BKP was 3.8%, with split type fracture, greater angular motion and large endplate deficit being risk factors for revision. Treatment strategies for patients with these risk factors should be carefully evaluated, considering the inherent difficulties in performing revision surgery after BKP.

Prognostic value of low psoas muscle mass in patients with cervical spine metastasis.

Morphometric analyses have shown that the psoas muscle mass is associated with mortality in cancer patients. Because of the low incidence of cervical spine metastasis, few studies have been reported in this population. The present study aimed to identify the prognostic value of a psoas muscle mass in predicting overall survival. We also evaluated factors associated with surgical intervention for cervical spine metastases. We retrospectively evaluated 97 patients (mean age 65.2 years) diagnosed with cervical spine metastases between February 2009 and July 2016. The psoas muscle area was measured at the L3 level on computed tomography at the time nearest the diagnosis of cervical spine metastasis. Cox proportional hazards analyses were performed to evaluate the relation between overall survival and the psoas muscle's composition. The mean overall survival for patients who underwent surgery was not significantly different from that for those without surgery. Multivariate analyses showed that the lowest percentage quartile (0%-25%) of the psoas muscle mass was associated with poor overall survival after adjusting for age and the prognostic predictive value (hazard ratio 1.93, 95% confidence interval 1.12-3.32; p = 0.017). Spinal cord compression, spinal instability, palsy, and the poor prognostic predictive value were factors associated with surgical intervention. In conclusion, a psoas muscle mass in the lowest quartile was independently associated with shorter survival among patients with cervical spine metastases. Although the poor prognostic predictive value was associated with surgical treatment, the overall survival was not different between patients who did or did not undergo surgery.

Intraoperative computed tomography with an integrated navigation system versus freehand technique under fluoroscopy in the treatment of intra-articular distal radius fractures.

Volar locking plate (VLP) fixation for distal radius fractures (DRF) is a technically demanding procedure, where accurate placement of the distal screws for subchondral articular support is essential. The purpose of this retrospective, case-control study was to compare a computed tomography (CT) navigation system for VLP fixation of intra-articular DRF with conventional freehand fluoroscopy guided surgery. Twelve consecutive patients with DRF, AO type C3.1, underwent VLP fixation using intraoperative CT navigation (navigated group) and 16 consecutive patients had conventional freehand fluoroscopy guided surgery (non-navigated group). Follow-up was done mean 12 (range, 4-18) months after surgery. Radiological outcomes included evaluation of placement for the distal fixation screws and radiological parameters such as; radial inclination, palmar tilt, ulnar variance, fracture-gap, and step-off. Clinical outcomes included grip strength, wrist range of motion, Mayo wrist score, and the Disabilities of the arm, shoulder and hand (DASH) questionnaire. Dorsal cortical and articular screw penetrations were significantly more common in the non-navigated group compared with the navigated group. At the final follow-up, a significantly larger intra-articular fracture gap was observed in the non-navigated group compared to the navigated group. There were no significant differences in clinical outcomes between the two treatment groups. Our results suggest that CT navigation guided surgery for VLP fixation of type C3 DRF, compared with conventional freehand fluoroscopy guided surgery, provides a more accurate placement of the distal screws which minimize the risk for intra-articular and dorsal cortical screw penetration.

Development of a scoring system for predicting adjacent vertebral fracture after balloon kyphoplasty.

BACKGROUND CONTEXT: The incidence of adjacent vertebral fracture (AVFs) is reported to be 10%-38% after balloon kyphoplasty. However, no reports have established a system for prediction of AVF occurrence. PURPOSE: To establish a scoring system for predicting AVF occurrence after balloon kyphoplasty for osteoporotic vertebral fractures (OVFs). DESIGN: A prospective cohort study. PATIENT SAMPLE: Consecutive elderly patients aged 65 years and older who underwent balloon kyphoplasty for OVFs within 2 months after the onset. OUTCOME MEASURES: AVF was confirmed by X-ray. METHODS: From 2015 to 2017, 116 consecutive patients from 10 participating hospitals who underwent balloon kyphoplasty were enrolled in this study. Prior to study enrollment, each patient underwent plain X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) of the thoracic and lumbar spine. Severity of pain was subjectively assessed using a visual analog scale (VAS) based on the average level of back pain that the patient had experienced in the preceding week. After enrollment, subjects underwent balloon kyphoplasty. Quality of life was evaluated using SF-36. Patients were followed up for at least 6 months. RESULTS: Of the 116 patients enrolled, 109 patients with all the required data at the time of enrolment and the 6-month follow-up were included in the study. A total of 32 patients (29%) showed AVFs within the 6-month follow-up. No significant differences were observed in each clinical outcome at 6-month follow-up, although higher VAS score for back pain at 1-month follow-up was observed in the AVF group (37.5) than in the non-AVF group (20.8, p<.001). Wedge angle of vertebrae before surgery was greater in the AVF group (21.6°) than in the non-AVF group (15.7°, p<.001). The change in wedge angle between pre- and postsurgery was greater in the AVF group than in the non-AVF group, whereas the change in local kyphosis was not significantly different. The multiple logistic regression model showed increased odds ratio (OR) of thoracic or thoracolumbar spine, old OVF presence, >25° kyphosis before surgery, and >10°correction for AVF. Based on this result, a simple scoring system for predicting AVF occurrence was developed. The total AVF score was calculated as the sum of the individual scores, which varied from 0 to 6. All patients with 5-6 points sustained AVF. CONCLUSIONS: More severe wedge angle before surgery, correction degree, old OVF presence, and thoracolumbar level were predictive factors for AVF. All patients with AVF risk score of 5 or more showed AVF. This information may aid preoperative risk assessment, informed shared decision-making, and consideration of potential alternative management strategies.

ISSLS PRIZE IN CLINICAL SCIENCE 2019: clinical importance of trunk muscle mass for low back pain, spinal balance, and quality of life-a multicenter cross-sectional study.

STUDY DESIGN: A multicenter cross-sectional study. OBJECTIVES: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear. METHODS: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score. RESULTS: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg. CONCLUSIONS: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. These slides can be retrieved under Electronic Supplementary Material.

Association between MRI findings and back pain after osteoporotic vertebral fractures: a multicenter prospective cohort study.

BACKGROUND CONTEXT: Osteoprotic vertebral fractures (OVFs) are common in elderly people. The association between back pain due to OVF with magnetic resonance imaging (MRI) signal change is unclear. In this study we hypothesized that MRI findings would be a predictive factor for back pain measured by visual analogue scale (VAS) at 6 months follow-up. PURPOSE: The aim was to study the MRI findings that predict back pain after OVF and the association between radiological findings and scores of back pain. STUDY DESIGN: Multicenter prospective cohort study. PATIENT SAMPLE: A total of 153 OVF patients. OUTCOME MEASURE: The outcome measures were VAS back pain and MRI signal change. METHODS: This study was performed from 2012 to 2015. Consecutive patients with less than 2-week-old OVFs at 11 institutions were enrolled prospectively. MRI was performed at enrollment and at 1, 3, and 6 months follow-up. T1- and T2-weighted images (T1WI and T2W1) were obtained at each time point and their association with VAS scores of back pain at 6 months were investigated. Anterior compression ratio, posterior compression ratio, and angular motion of vertebral bodies were also measured on X-rays at each follow-up. This research had no financial support. There are no conflicts of interest. RESULT: The 6 months follow-up was completed by 153 patients. At enrollment, the average VAS score of back pain was 75 mm, and it had improved at the 6-month follow-up to an average score of 20 mm. There was a significant correlation between T1 diffuse low signal change and VAS scores at the 6-month follow-up (p<.01). T2 high signal changes (odds ratio; 4.01, p<.01) and old vertebral fractures (odds ratio; 2.47, p=.04) were independent risk factors for back pain. The correlation between angular motion of vertebrae on X-rays and the VAS score of back pain was significant at all time points. CONCLUSION: This study demonstrates the radiological factors associated with persistent back pain after an OVF and the association between the VAS score of back pain and radiological findings. In addition, T2 high signal changes in acute phase and old vertebral fractures were independent risk factors for residual back pain.

Prognostic value of paravertebral muscle density in patients with spinal metastases from gastrointestinal cancer.

PURPOSE: Morphometric analyses have shown that trunk muscle mass and density are associated with mortality in cancer patients. Because of the low incidence of spinal metastasis from gastrointestinal cancer and the limited life expectancy of these patients, few studies have been reported in this population. We evaluated the prognostic value of trunk muscle area and density in predicting overall survival. METHODS: The data from 78 patients with spinal metastases from gastrointestinal cancer, collected from February 2009 to July 2016, were evaluated. Psoas muscle and paravertebral muscle area and density were measured at the L3 level on CT scans taken at the time nearest to the diagnosis of spinal metastasis. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS: The mean patient age was 68.3 years (range, 42-88 years). The overall median survival time was 4.8 months: 2.2 months in the extremely rapid growth group (stomach, biliary tract, and pancreas) and 7.6 months in the rapid growth group (esophagus, liver, and colorectum). Multivariate analyses showed that lower paravertebral muscle density (HR 2.23 [95% CI 1.24-3.99], p = 0.007), extremely rapid growth group, presence of abnormal laboratory data, poor performance status, and chemotherapy after spinal metastasis were independent prognostic factors. CONCLUSIONS: Median overall survival was poor among patients with spinal metastases from gastrointestinal carcinoma, especially among those with gastric, biliary tract, or pancreatic cancer. Lower paravertebral muscle density was an independent poor prognostic factor in patients with spinal metastases from gastrointestinal cancer.

The degeneration of adjacent intervertebral discs negatively influence union rate of osteoporotic vertebral fracture: A multicenter cohort study.

BACKGROUND: With the increasing aging population in developed countries, there has been an associated increased prevalence of osteoporotic vertebral fracture (OVF). Many previous reports have attempted to predict the risk of delayed union associated with OVF. However, the role of endplate failure and the degeneration of adjacent intervertebral discs, and their association with delayed union has received little attention. The aim of this study was to evaluate the endplate fracture and disc degeneration rank as risk factors for delayed union. MATERIALS AND METHODS: Two hundred and eighteen consecutive patients with fresh OVF were enrolled in the study. MRI and X-ray were performed at the time of enrollment and at the 6 months follow-up. The MR images were used to assess the degeneration grade of adjacent intervertebral discs (using the modified Pfirrmann grading system), and endplate failure. Supine and weight-bearing radiographs were used to define angular motion and compression ratio of the anterior vertebral body wall. RESULTS: A total of 139 patients (112 female, 27 male) completed the 6 month follow-up (a 65.1% follow-up rate). The study revealed 27 cases of delayed union (19.4%). A healthier adjacent caudal disc with low grade degeneration was found to be associated with an increased risk of delayed union (P = 0.008). Bi-endplate injury and significant compression of the anterior vertebral body wall were significantly associated with delayed union (P = 0.019, and P = 0.001 respectively). Rapid progression of the adjacent cranial disc degeneration was observed at the end of the 6 month follow-up period (P = 0.001). CONCLUSION: Modified Pfirrmann grading system revealed that a healthier adjacent intervertebral disc at the caudal level and bi-endplate fracture were significantly associated with an increased risk of delayed union. These findings may influence the management strategy for patients with OVF.

Differences in short-term clinical and radiological outcomes depending on timing of balloon kyphoplasty for painful osteoporotic vertebral fracture.

BACKGROUND: Balloon kyphoplasty or vertebroplasty is widely performed as a surgical intervention for osteoporotic vertebral fracture (OVF) and the effects have been investigated in many previous studies. However, the influence of the timing of the procedure on patient outcomes has not been studied formally. The purpose of this study was to investigate differences in the surgical outcomes of OVFs according to the timing of balloon kyphoplasty. METHODS: This was a multicenter cohort study. Participants comprised 72 consecutive patients who underwent balloon kyphoplasty between January 2012 and January 2016. Patients were analyzed in two groups according to the timing of kyphoplasty after onset (Early group: ≤2 months; Late group: >2 months). Follow-up continued for more than 6 months. RESULTS: A total of 72 patients were effectively analyzed. Of these, 27 (38%) patients underwent kyphoplasty within 2 months after symptom onset. The Late group showed greater angular motion of fractured vertebrae (p = 0.005) and compression of anterior vertebral height (p = 0.001) before surgery. Final outcomes adjusted for age and preoperative outcome showed lower visual analog scale (VAS) scores for low back pain in the Early group than in the Late group (19.9 vs. 30.4, p = 0.049). Final relative anterior vertebral height and kyphotic angle were more preserved in the Early group than in the Late group (p = 0.002 and p = 0.020, respectively), although absolute differences were not significant. CONCLUSIONS: Vertebral height and kyphotic angle before and after balloon kyphoplasty were greater in patients who underwent kyphoplasty within 2 months after onset, and the VAS score for low back pain at final follow-up was better. Our results support kyphoplasty within 2 months.

Characterizing the course of back pain after osteoporotic vertebral fracture: a hierarchical cluster analysis of a prospective cohort study.

This study demonstrated four distinct patterns in the course of back pain after osteoporotic vertebral fracture (OVF). Greater angular instability in the first 6 months after the baseline was one factor affecting back pain after OVF. PURPOSE: Understanding the natural course of symptomatic acute OVF is important in deciding the optimal treatment strategy. We used latent class analysis to classify the course of back pain after OVF and identify the risk factors associated with persistent pain. METHODS: This multicenter cohort study included 218 consecutive patients with ≤ 2-week-old OVFs who were enrolled at 11 institutions. Dynamic x-rays and back pain assessment with a visual analog scale (VAS) were obtained at enrollment and at 1-, 3-, and 6-month follow-ups. The VAS scores were used to characterize patient groups, using hierarchical cluster analysis. RESULTS: VAS for 128 patients was used for hierarchical cluster analysis. Analysis yielded four clusters representing different patterns of back pain progression. Cluster 1 patients (50.8%) had stable, mild pain. Cluster 2 patients (21.1%) started with moderate pain and progressed quickly to very low pain. Patients in cluster 3 (10.9%) had moderate pain that initially improved but worsened after 3 months. Cluster 4 patients (17.2%) had persistent severe pain. Patients in cluster 4 showed significant high baseline pain intensity, higher degree of angular instability, and higher number of previous OVFs, and tended to lack regular exercise. In contrast, patients in cluster 2 had significantly lower baseline VAS and less angular instability. CONCLUSIONS: We identified four distinct groups of OVF patients with different patterns of back pain progression. Understanding the course of back pain after OVF may help in its management and contribute to future treatment trials.

Overall survival and prognostic factors in patients with spinal metastases from lung cancer treated with and without epidermal growth factor receptor tyrosine kinase inhibitors.

BACKGROUND: Evaluation of the prognosis in patients with spinal metastases is important in decision making regarding surgical treatment. The purpose of this study was to investigate overall survival in patients with spinal metastases from lung cancer by histological subtype, and to investigate prognostic factors in patients treated with and without epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). METHODS: The data from 135 patients diagnosed with spinal metastases from lung cancer were retrospectively evaluated. The 88 patients with adenocarcinoma were divided into two groups according to whether the lung cancer was treated with or without EGFR-TKIs-the EGFR-TKI group (n = 43) and the non-EGFR-TKI group (n = 45). RESULTS: The overall median survival time was 11.3 months for those with adenocarcinoma, 5.3 months for squamous cell carcinoma, and 3.9 months for small cell carcinoma. Overall survival in the EGFR-TKI group (median 21.4 months) was significantly longer than in the non-EGFR-TKI group (median 6.1 months). In univariate analysis, poor performance status was a poor prognostic factor in the non-EGFR-TKI group. However, performance status and other variables were not significant prognostic factors in the EGFR-TKI group. CONCLUSIONS: Median overall survival was longer in patients with spinal metastases from lung cancer treated with EGFR-TKIs compared with those treated without EGFR-TKIs. Poor performance status or other prognostic factors were not associated with poor overall survival in the group treated with EGFR-TKIs.