Voice Restoration and Quality of Life in Larynx Cancer.

Voice restoration following laryngectomy has a significant influence on quality of life (QOL). Three main techniques exist to provide voice: esophageal speech (ES), artificial larynx (electrolarynx [EL]), and tracheoesophageal puncture (TEP). Although the EL was historically the most used technique, TEP has quickly become the gold standard. ES remains the least frequently used technique in developed countries. Technique selection must be made on an individual basis, considering the patient's cancer history and comorbidities. Ultimately, the choice in voice-restoration technique requires joint decision making with the surgeon, speech pathologist, and patient.

Clinical and Histologic Features Associated With Malignant Transformation of Oral Cavity Dysplasia Managed at a Single North American Institution.

Importance: Reports characterizing clinical and histologic features associated with a higher risk for development of malignant lesions in the background of an oral potentially malignant disorder have largely reflected East Asian populations. Long-term studies among the North American population are rare. Objective: To evaluate risk of malignant transformation (MT) of oral dysplastic lesions by investigating the demographic, social, clinical, and histologic factors that may be associated with an increased rate as well as a decreased time to MT. Design, Setting, and Participants: This was a retrospective cohort study with medical record review at a single institution from January 1, 2000, to December 31, 2019, with follow-up for 20 years. Patients were excluded if they were younger than 18 years, the first biopsy diagnosis showed cancer, biopsies were never performed, biopsies were taken from sites outside of the oral cavity, there was no additional follow-up after the first visit, or the biopsy specimen was not characterized on the spectrum of dysplasia. Exposures: Diagnosis of leukoplakia of oral mucosa, unspecified lesions of oral mucosa, or other disturbances of oral epithelium. Main Outcomes and Measures: Main outcome measures included MT rate and time to MT as well as demographic, social, clinical, physical, and histologic features associated with MT. Results: Thirty-eight of 264 lesions (14%) in 241 patients (132 men and 109 women; mean [SD] age, 64 [13] years) underwent MT. Of the 38 lesions that underwent MT, 19 (50%) underwent transformation by 424 days, 28 (75%) by 870 days, and 34 (90%) by 1600 days. Nodularity, friability, and mass effect were more commonly observed in malignant lesions (nodularity: 42.9% vs 10.0%; difference, 32.9%; OR, 6.72; 95% CI, 3.03-14.89; friability: 42.9% vs 12.8%; difference, 30.1%; OR, 5.11; 95% CI, 1.66-15.69; mass effect: 54.2% vs 10.4%; difference, 43.8%; OR, 10.16; 95% CI, 4.12-25.09). Men were less likely than women to have multiple lesions in the oral cavity (OR, 0.40; 95% CI, 0.22-0.74). Having multiple abnormal sites was associated with higher percentage of MT (OR, 3.38; 95% CI, 1.63-7.01). Conclusions and Relevance: In this cohort study, nodularity and mass effect were associated with lesions that may push, displace, or invade surrounding tissue, and these were more likely to be present in oral dysplastic lesions that ultimately progressed to cancer. There may be less utility in continuing surveillance beyond 5 years.

Laryngeal inhalational injuries: A systematic review.

Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.

Diverging incidence trends for larynx and tonsil cancer in low socioeconomic regions of the US.

OBJECTIVE: Oropharynx cancer incidence trends in low socioeconomic (SES) regions of the United States (US) have not been well described. Our objective was to describe tonsil cancer incidence trends in low SES regions, and compare observed trends with those for larynx cancer. MATERIALS AND METHODS: Age-adjusted incidence rates and trends for tonsil and larynx squamous cell carcinomas (2000-14) from Surveillance, Epidemiology, and End Results (SEER 18) were evaluated using SEER*Stat and Joinpoint 4.5.0.1. Annual percentage changes (APCs) were compared between low and high SES counties. The laryngeal cancer cohort was included as a comparator reflecting a tobacco-related malignancy. RESULTS: Tonsil cancer incidence trends increased at least as much in low SES as in high SES counties (APC/AAPC 4.4, 95%CI 2.4-6.4 versus APC/AAPC 2.9, 95%CI 2.4-3.3). Pairwise comparison confirmed no differences between incidence trends across SES quintiles for tonsil cancer incidence rates. In contrast, age-adjusted incidence rates of larynx cancer decreased in high SES counties (APC/AAPC -2.4, 95%CI -2.4 to -2.0, p < 0.001) and were stable in low SES counties (APC/AAPC -0.9, 95%CI -1.9 to 0.2, p = 0.10). Compared with larynx cancer patients, tonsil cancer patients in low SES regions were significantly more likely to be younger and white. CONCLUSION: In low SES US counties, tonsil cancer incidence rates increased from 2000 to 2014, while larynx cancer rates did not change, reflecting diverging trends for larynx and tonsil cancers. Tonsil cancer incidence rates are increasing in most US regions regardless of regional socioeconomic status. Prevention efforts should take these findings into account.

Parathyroidectomy for the treatment of hyperparathyroidism: Thirty-day morbidity and mortality.

OBJECTIVES/HYPOTHESIS: Evaluate morbidity and mortality rates for patients with different levels of hyperparathyroidism (HPT) undergoing parathyroidectomy (PTX), specifically comparing primary hyperparathyroidism to secondary and tertiary hyperparathyroidism. Assess predictive factors of increased morbidity and mortality. STUDY DESIGN: Retrospective national database review. METHODS: Patients undergoing PTX, defined by Current Procedural Terminology codes 60500, 60502, 60505, for the treatment of HPT, were identified in the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2014. Incidence of morbidity and mortality was calculated for primary, secondary, and tertiary HPT. A t test, analysis of variance, and χ2 analyses were used to assess preoperative characteristics among the three groups. RESULTS: A total of 21,267 patients were included in the analysis. There was an overall 7.2% morbidity and mortality rate, including 45 (0.21%) deaths, a 1.8% readmission rate, and a 1.9% reoperation rate, but morbidity and mortality rates were widely divergent when comparing primary to secondary and tertiary HPT. PTX resulted in a 4.9% morbidity and mortality rate for primary HPT (n = 14,500), 26.8% morbidity and mortality rate for secondary HPT (n = 1661), and 21.8% morbidity and mortality rate for tertiary HPT (n = 588). The primary reason for readmission was hypocalcemia (18.3%). Hematoma (7.2%) and postoperative hemorrhage (3.3%) were the two most common causes of reoperation. Elevated preoperative serum creatinine, alkaline phosphatase, and hypertension resulted in a higher rate of complications after PTX (P < .0001). CONCLUSIONS: Although surgery for primary HPT is an extremely common and safe procedure with minimal morbidity and mortality rates, PTX for secondary and tertiary HPT has significantly higher rates of morbidity and mortality, requiring special attention in the postoperative period. Predictive factors of poor outcomes include hypertension, elevated creatinine, and elevated alkaline phosphatase. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:528-533, 2018.

Incidence of Lingual Tonsil Hypertrophy in Adults with and without Obstructive Sleep Apnea.

Objectives To characterize the incidence of lingual tonsil hypertrophy (LTH) in adults with and without obstructive sleep apnea (OSA) and to determine any potential correlation between them. Study Design Retrospective chart review. Setting Single-center database, September 2016 to April 2017. Subject and Methods Lingual tonsil grade (LTG) determined by awake endoscopy was collected as well as other physical examination findings, such as Friedman tongue position, palatine tonsil size, and neck circumference. STOP-BANG scores and polysomnography data were collected to characterize OSA. Incidence of clinically meaningful LTH (defined as LTG 3 and LTG 4) was compared between OSA and non-OSA groups. Results Ninety-three patient charts were studied in total. There was no significant difference between patients with and without OSA in the incidence of clinically meaningful LTH (OSA, 13.5%; non-OSA, 14.6%; P = .872). Patients with and without OSA were compared by grade: LTG 1, 13.5% (OSA) vs 35.6% (non-OSA); LTG 2, 73.1% (OSA) vs 48.8% (non-OSA); LTG 3, 13.5% (OSA) vs 14.6% (non-OSA). There were no significant correlations between OSA status and LTG (ρ = 0.190, P = .069). Conclusion The incidence of LTH is uncommon, even among those with OSA, and does not seem to differ between patients with and without OSA. Neck circumference appears to be a better clinical indicator than lingual tonsil tissue for the likelihood of a patient having OSA.

Comparison between Awake Endoscopy and Computed Tomography to Define Lingual Tonsil Hypertrophy.

Objectives To analyze correlations between endoscopic lingual tonsil grade (LTG) by the Friedman Lingual Tonsil Hypertrophy grading system and computed tomography (CT) measurements of lingual tonsil thickness (LTT). Study Design Retrospective chart review. Setting Single-center database, September 2016 to April 2017. Subjects and Methods Patients who received CT covering base of tongue and endoscopic LTG were included. LTT was measured on axial and sagittal CT. LTT measurements were compared against endoscopic LTG. One-way analysis of variance with Tukey's post hoc adjustment for multiple comparisons was performed. Results Seventy-five charts were included for a total of 150 LTT measurements. Axial CT measurements of LTG 1 and LTG 2 were each significantly different from LTG 3 ( P < .001 for both), and LTG 1 and LTG 2 also differed significantly ( P = .010). Mean sagittal CT measurements were significantly different between LTG 1 and LTG 3 ( P < .001) and between LTG 2 and LTG 3 ( P = .002) but not between LTG 1 and LTG 2 ( P = .186). Those without lingual tonsil hypertrophy had a mean axial CT thickness of 6.45 ± 1.39 mm and mean sagittal CT thickness of 6.58 ± 1.53 mm, which was significantly different from both the mean axial CT thickness of 8.48 ± 1.52 mm and the mean sagittal CT thickness of 8.07 ± 1.16 mm in the LTG 3 group ( P < .001 for both). Threshold analysis showed a potential cutoff of approximately 7.5 mm on axial and sagittal CT for defining clinically significant lingual tonsil hypertrophy. Conclusion Awake endoscopy grading of lingual tonsil hypertrophy is a subjective measurement that seems to correlate with objective CT measurements. LTT measurements of LTG 1 and LTG 2 on awake endoscopy differed significantly from LTG 3.

Parathyroidectomy for tertiary hyperparathyroidism: A systematic review.

OBJECTIVE: Analyze the efficacy and indications for parathyroidectomy as an intervention for tertiary hyperparathyroidism. DATA SOURCES: PubMed, MEDLINE, and Cochrane Library databases. REVIEW METHODS: A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms ("tertiary hyperparathyroidism" OR "3HPT") AND "parathyroidectomy". Articles were analyzed in regards to their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management. RESULTS: Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. The majority of studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches. CONCLUSION: Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a >50% drop in PTH level even if PTH remains above normal. Additionally, "success" or "cure" is defined as normal calcium levels regardless of whether or not PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.

Long-Term Incidence of Velopharyngeal Insufficiency and Other Sequelae following Uvulopalatopharyngoplasty.

Objective The aim of this study is to (1) assess incidence of long-term velopharyngeal insufficiency (VPI) and (2) determine other sequelae following classic and modified uvulopalatopharyngoplasty (UPPP and mUPPP) for treatment of obstructive sleep apnea (OSA). Data Sources Medline, PubMed, Cochrane Library database. Review Methods A systematic review was performed following standard Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Original research articles reporting on sequelae of UPPP and mUPPP for treatment of OSA, at a mean of 1 year follow-up, were included. Articles were retrieved using keywords UPPP complications and UPPP questionnaire. A random-effects model was used for pooling data. Results A total of 24 studies were included in this review. Complications included VPI (24 studies, n = 191), difficulty swallowing (7 studies, n = 83), taste disturbances (4 studies, n = 10), voice changes (7 studies, n = 46), foreign body (9 studies, n = 427), and dry pharynx (7 studies, n = 150). When pooling all studies together, VPI was the least common sequelae reported in 8.1% of the cases. Foreign body sensation was the most commonly reported sequelae at 31.2%, with difficulty swallowing (17.7%), dry pharynx (23.4%), voice changes (9.5%), and taste disturbances (8.2%) being the most to least likely. Conclusions The long-term effectiveness of UPPP and mUPPP is limited by the number of studies reporting short-term follow-up only. Despite this, long-term data suggest that complications such as VPI are more common than previously reported. Other sequelae, such as foreign body sensation, may be one of the most frequently expected complications after UPPP surgery.

Coevolution of Peer-Reviewed Literature and Clinical Practice in High-Grade Glioma Resection.

BACKGROUND: The paradigm of evidence-based medicine dictates that clinical practice should reflect the shifting landscape of the peer-reviewed literature. Here, we examined the extent to which this premise is fulfilled as it pertains to the surgical resection of high-grade gliomas (HGGs). OBJECTIVE: We assessed trends in published literature regarding HGG survival after resection in conjunction with trends in clinical practice patterns of HGG resection. METHODS: We performed a comprehensive PubMed search to identify articles that examined whether gross total resection (GTR) improves HGG survival. Temporal trends in the literature were compared with rates of GTR in the Surveillance Epidemiology and End Results (SEER) database, the Veterans Health Administration database, and published data series from academic neuro-oncology centers. RESULTS: Before 2000, the ratio of articles supporting survival benefit of GTR relative to those not supporting it ranged from approximately 1:5 to 1:1. Since 2000, this ratio has steadily increased such that by the post-2013 period, 32 of the 33 published articles (>30:1) supported the survival benefit of GTR. Although the frequency of GTR increased during the 2000-2004 period in the SEER and Veterans Health Administration database, no further increase in the frequency of GTR was observed thereafter. In contrast, resection rates in academic neuro-oncology centers continued to increase subsequent to 2004. CONCLUSIONS: Our results indicate that clinical practice patterns mirror publication patterns for HGG resection, suggesting that neurosurgical oncology is a field in which clinical practice is informed by the peer-reviewed literature.

'Journal Bias' in peer-reviewed literature: an analysis of the surgical high-grade glioma literature.

The core premise of evidence-based medicine is that clinical decisions are informed by the peer-reviewed literature. To extract meaningful conclusions from this literature, one must first understand the various forms of biases inherent within the process of peer review. We performed an exhaustive search that identified articles exploring the question of whether survival benefit was associated with maximal high-grade glioma (HGG) resection and analysed this literature for patterns of publication. We found that the distribution of these 108 articles among the 26 journals to be non-random (p<0.01), with 75 of the 108 published articles (69%) appearing in 6 of the 26 journals (25%). Moreover, certain journals were likely to publish a large number of articles from the same medical academic genealogy (authors with shared training history and/or mentor). We term the tendency of certain types of articles to be published in select journals 'journal bias' and discuss the implication of this form of bias as it pertains to evidence-based medicine.

Impact of medical academic genealogy on publication patterns: An analysis of the literature for surgical resection in brain tumor patients.

"Academic genealogy" refers to the linking of scientists and scholars based on their dissertation supervisors. We propose that this concept can be applied to medical training and that this "medical academic genealogy" may influence the landscape of the peer-reviewed literature. We performed a comprehensive PubMed search to identify US authors who have contributed peer-reviewed articles on a neurosurgery topic that remains controversial: the value of maximal resection for high-grade gliomas (HGGs). Training information for each key author (defined as the first or last author of an article) was collected (eg, author's medical school, residency, and fellowship training). Authors were recursively linked to faculty mentors to form genealogies. Correlations between genealogy and publication result were examined. Our search identified 108 articles with 160 unique key authors. Authors who were members of 2 genealogies (14% of key authors) contributed to 38% of all articles. If an article contained an authorship contribution from the first genealogy, its results were more likely to support maximal resection (log odds ratio = 2.74, p < 0.028) relative to articles without such contribution. In contrast, if an article contained an authorship contribution from the second genealogy, it was less likely to support maximal resection (log odds ratio = -1.74, p < 0.026). We conclude that the literature on surgical resection for HGGs is influenced by medical academic genealogies, and that articles contributed by authors of select genealogies share common results. These findings have important implications for the interpretation of scientific literature, design of medical training, and health care policy.

Comparison of Expandable and Fixed Interbody Cages in a Human Cadaver Corpectomy Model: Fatigue Characteristics.

STUDY DESIGN: In vitro cadaver biomechanics study. OBJECTIVE: The goal of this study is to compare the in situ fatigue life of expandable versus fixed interbody cage designs. SUMMARY OF BACKGROUND DATA: Expandable cages are becoming more popular, in large part, due to their versatility; however, subsidence and catastrophic failure remain a concern. This in vitro analysis investigates the fatigue life of expandable and fixed interbody cages in a single level human cadaver corpectomy model by evaluating modes of subsidence of expandable and fixed cages as well as change in stiffness of the constructs with cyclic loading. METHODS: Nineteen specimens from 10 human thoracolumbar spines (T10-L2, L3-L5) were biomechanically evaluated after a single level corpectomy that was reconstructed with an expandable or fixed cage and anterior dual rod instrumentation. All specimens underwent 98 K cycles to simulate 3 months of postoperative weight bearing. In addition, a third group with hyperlordotic cages was used to simulate catastrophic failure that is observed in clinical practice. RESULTS: Three fixed and 2 expandable cages withstood the cyclic loading despite perfect sagittal and coronal plane fitting of the endcaps. The majority of the constructs settled in after initial subsidence. The catastrophic failures that were observed in clinical practice could not be reproduced with hyperlordotic cages. However, all cages in this group subsided, and 60% resulted in endplate fractures during deployment of the cage. CONCLUSIONS: Despite greater surface contact area, expandable cages have a trend for higher subsidence rates when compared with fixed cages. When there is edge loading as in the hyperlordotic cage scenario, there is a higher risk of subsidence and intraoperative fracture during deployment of expandable cages.

Survival trends of grade I, II, and III astrocytoma patients and associated clinical practice patterns between 1999 and 2010: A SEER-based analysis.

BACKGROUND: The survival trends and the patterns of clinical practice pertaining to radiation therapy and surgical resection for WHO grade I, II, and III astrocytoma patients remain poorly characterized. METHODS: Using the Surveillance, Epidemiology and End Results (SEER) database, we identified 2497 grade I, 4113 grade II, and 2755 grade III astrocytomas during the period of 1999-2010. Time-trend analyses were performed for overall survival, radiation treatment (RT), and the extent of surgical resection (EOR). RESULTS: While overall survival of grade I astrocytoma patients remained unchanged during the study period, we observed improved overall survival for grade II and III astrocytoma patients (Tarone-Ware P < .05). The median survival increased from 44 to 57 months and from 15 to 24 months for grade II and III astrocytoma patients, respectively. The differences in survival remained significant after adjusting for pertinent variables including age, ethnicity, marital status, sex, tumor size, tumor location, EOR, and RT status. The pattern of clinical practice in terms of EOR for grade II and III astrocytoma patients did not change significantly during this study period. However, there was decreased RT utilization as treatment for grade II astrocytoma patients after 2005. CONCLUSION: Results from the SEER database indicate that there were improvements in the overall survival of grade II and III astrocytoma patients over the past decade. Analysis of the clinical practice patterns identified potential opportunities for impacting the clinical course of these patients.

Outcomes of thyroidectomy from a large California state database.

BACKGROUND: Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California. METHODS: The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications. RESULTS: There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confidence interval, .6 to .97; P = .026). CONCLUSIONS: Older age was a significant risk factor for complication after thyroidectomy. High-volume hospitals had lower risk. This information is useful in counseling patients about the risks of thyroid surgery.

The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery.

BACKGROUND: Positive spinal regional and global sagittal malalignment has been repeatedly shown to correlate with pain and disability in thoracolumbar fusion. OBJECTIVE: To evaluate the relationship between regional cervical sagittal alignment and postoperative outcomes for patients receiving multilevel cervical posterior fusion. METHODS: From 2006 to 2010, 113 patients received multilevel posterior cervical fusion for cervical stenosis, myelopathy, and kyphosis. Radiographic measurements made at intermediate follow-up included the following: (1) C1-C2 lordosis, (2) C2-C7 lordosis, (3) C2-C7 sagittal vertical axis (C2-C7 SVA; distance between C2 plumb line and C7), (4) center of gravity of head SVA (CGH-C7 SVA), and (5) C1-C7 SVA. Health-related quality-of-life measures included neck disability index (NDI), visual analog pain scale, and SF-36 physical component scores. Pearson product-moment correlation coefficients were calculated between pairs of radiographic measures and health-related quality-of-life scores. RESULTS: Both C2-C7 SVA and CGH-C7 SVA negatively correlated with SF-36 physical component scores (r =-0.43, P< .001 and r =-0.36, P = .005, respectively). C2-C7 SVA positively correlated with NDI scores (r = 0.20, P = .036). C2-C7 SVA positively correlated with C1-C2 lordosis (r = 0.33, P = .001). For significant correlations between C2-C7 SVA and NDI scores, regression models predicted a threshold C2-C7 SVA value of approximately 40 mm, beyond which correlations were most significant. CONCLUSION: Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increases with positive sagittal malalignment following surgical reconstruction.

Malignant peripheral nerve sheath tumors of the spine: a SEER database analysis.

Peripheral nerve sheath tumors are uncommon neoplasms that can affect any area of the body. Spinal lesions, especially those that are malignant, pose difficult management challenges, and data regarding these lesions are limited by the disease rarity. This study provides a population-based analysis using the Surveillance, Epidemiology, and End Results (SEER) database, focusing on patient characteristics and treatments. Surgery is associated with improved survival, whereas radiation therapy is associated with decreased survival in this cohort with malignant peripheral nerve sheath tumor in the spine.

Gait-simulating fatigue loading analysis and sagittal alignment failure of spinal pelvic reconstruction after total sacrectomy: comparison of 3 techniques.

OBJECT: Reconstruction after total sacrectomy is a critical component of malignant sacral tumor resection, permitting early mobilization and maintenance of spinal pelvic alignment. However, implant loosening, graft migration, and instrumentation breakage remain major problems. Traditional techniques have used interiliac femoral allograft, but more modern methods have used fibular or cage struts from the ilium to the L-5 endplate or sacral body replacement with transiliac bars anchored to cages to the L-5 endplate. This study compares the biomechanical stability under gait-simulating fatigue loading of the 3 current methods. METHODS: Total sacrectomy was performed and reconstruction was completed using 3 different constructs in conjunction with posterior spinal screw rod instrumentation from L-3 to pelvis: interiliac femur strut allograft (FSA); L5-iliac cage struts (CSs); and S-1 body replacement expandable cage (EC). Intact lumbar specimens (L3-sacrum) were tested for flexion-extension range of motion (FE-ROM), axial rotation ROM (AX-ROM), and lateral bending ROM (LB-ROM). Each instrumented specimen was compared with its matched intact specimen to generate an ROM ratio. Fatigue testing in compression and flexion was performed using a custom-designed long fusion gait model. RESULTS: Compared with intact specimen, the FSA FE-ROM ratio was 1.22 ± 0.60, the CS FE-ROM ratio was significantly lower (0.37 ± 0.12, p < 0.001), and EC was lower still (0.29 ± 0.14, p < 0.001; values are expressed as the mean ± SD). The difference between CS and EC in FE-ROM ratio was not significant (p = 0.83). There were no differences in AX-ROM or LB-ROM ratios (p = 0.77 and 0.44, respectively). No failures were noted on fatigue testing of any EC construct (250,000 cycles). This was significantly improved compared with FSA (856 cycles, p < 0.001) and CS (794 cycles, p < 0.001). CONCLUSIONS: The CS and EC appear to be significantly more stable constructs compared with FSA with FE-ROM. The 3 constructs appear to be equal with AX-ROM and LB-ROM. Most importantly, EC appears to be significantly more resistant to fatigue compared with FSA and CS. Reconstruction of the load transfer mechanism to the pelvis via the L-5 endplate appears to be important in maintenance of alignment after total sacrectomy reconstruction.

Gross-total resection outcomes in an elderly population with glioblastoma: a SEER-based analysis.

OBJECT: There is limited information on the relationship between patient age and the clinical benefit of resection in patients with glioblastoma. The purpose of this study was to use a population-based database to determine whether patient age influences the frequency that gross-total resection (GTR) is performed, and also whether GTR is associated with survival difference in different age groups. METHODS: The authors identified 20,705 adult patients with glioblastoma in the Surveillance, Epidemiology, and End Results (SEER) registry (1998-2009). Surgical practice patterns were defined by the categories of no surgery, subtotal resection (STR), and GTR. Kaplan-Meier and multivariate Cox regression analyses were used to assess the pattern of surgical practice and overall survival. RESULTS: The frequency that GTR was achieved in patients with glioblastoma decreased in a stepwise manner as a function of patient age (from 36% [age 18-44 years] to 24% [age ≥ 75]; p < 0.001). For all age groups, glioblastoma patients who were selected for and underwent GTR showed a 2- to 3-month improvement in overall survival (p < 0.001) relative to those who underwent STR. These trends remained true after a multivariate analysis that incorporated variables including ethnicity, sex, year of diagnosis, tumor size, tumor location, and radiotherapy status. CONCLUSIONS: Gross-total resection is associated with improved overall survival, even in elderly patients with glioblastoma. As such, surgical decisions should be individually tailored to the patient rather than an adherence to age as the sole clinical determinant.

The current trend of administering a patient-generated index in the oncological setting: a systematic review.

The patient-generated index (PGI) is a more novel approach to evaluating health-related quality of life (HRQOL) that allows patients to formulate their own responses in an open-ended format in order to measure HRQOL based on each patient's own stated goals and expectations. To date the use of PGI in the setting of patients diagnosed with cancer remains relatively less common compared to other health conditions. This systematic review primarily aims to identify current literature in which PGI has been used as a tool to assess quality of life in cancer patients. A systematic review using the MEDLINE database from January 1990 to July 2013 was performed with the following search terms to identify the implementation of PGI in oncology settings: (PGI OR patient generated index OR patient-generated OR patient-reported OR patient generated OR patient reported) AND (cancer OR oncology OR tumor OR neoplasm OR malignancy). Of the 2167 papers initially identified, 10 papers evaluated quality of life in oncology patients by collecting free-form responses from the patient, 4 of which actually used PGI. An overarching theme observed in these studies highlighted the concerns mentioned by patients that were not targeted or detected by standardized quality of life measures. While implementing the PGI may require slightly more investment of resources in the beginning, the potential implications of allowing patients to characterize their quality of life on their own terms are tremendous.