Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined. PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases. STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery. PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014. OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates. METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: <70, 70-80, and >80 years. RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70-80, and 17.9% for patients <70 years, p=.004). EQ-5D improved in all groups, but survival expectancy was significantly longer in patients <70 years old (p=.02). Furthermore, neurologic recovery after surgery was lower in patients >80 years old. CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated.

The prevalence of and factors related to calcium pyrophosphate dihydrate crystal deposition in the knee joint.

OBJECTIVES: The purpose of this study was to reveal the accurate prevalence and related factors to the presence of calcium pyrophosphate dihydrate (CPPD) crystal deposition in cadaveric knee joints. DESIGN: Controlled laboratory study. METHODS: Six hundred and eight knees from 304 cadavers (332 male knees and 276 female knees, formalin fixed, Japanese anatomical specimens) were included in this study. The average age of the cadavers was 78.3 ± 10.7 years. Knees were macroscopically evaluated for the existence of CPPD, and the depth of cartilage degeneration of the femoro-tibial joint following the Outerbridge's classification. CPPD crystal was confirmed under Fourier transform infrared spectroscopy (FTIR) analysis using light microscopy. Statistical analysis was performed to reveal the correlation between the occurrence of CPPD deposition in the knee joint and gender, age, and the depth of cartilage degeneration of the femoro-tibial joint. RESULTS: The prevalence of grossly visible CPPD crystal was 13% (79 knees). In all of these knees, CPPD crystal was confirmed under FTIR analysis. Statistical analysis showed significant correlation between the occurrence of CPPD deposition and gender (P < 0.001), and depth of cartilage degeneration in the femoro-tibial joint (P < 0.001). In the cartilage degeneration positive knees (Over grade 3 in Outerbridge's classification), average age of CPPD deposition knee was significantly higher than CPPD negative knees. CONCLUSIONS: In this study, the prevalence of CPPD deposition disease was evaluated in a relatively large sample size of cadaveric knees. The prevalence of CPPD deposition disease was 13%, and was significantly correlated with the subject's age, gender, and severity of cartilage degeneration in the femoro-tibial joint.

Symptoms of thoracolumbar junction disc herniation.

STUDY DESIGN: A retrospective clinical review of patients with thoracolumbar junction disc herniation. OBJECTIVES: To evaluate the clinical features of thoracolumbar junction disc herniation and to prepare a chart for the level diagnosis in the neurologic findings and symptoms. SUMMARY OF BACKGROUND DATA: Thoracolumbar junction disc herniations show a variety of signs and symptoms because of the complexity of the upper and lower neurons of the spinal cord, cauda equina, and nerve roots. Furthermore, much is still unknown about thoracolumbar junction disc herniations because of their rare frequency. METHODS: The clinical features of 26 patients who had undergone operations for single disc herniations at T10-T11 through L2-L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10-T11 disc, 4 patients at T11-T12, 3 patients at T12-L1, 6 patients at L1-L2, and 11 patients at L2-L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram. RESULTS: Two patients with T10-T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11-T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12-L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1-L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2-L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect of the thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results. CONCLUSION: Among thoracolumbar junction disc herniations, T10-T11 and T11-T12 disc herniations were considered upper neuron disorders, T12-L1 disc herniations were considered lower neuron disorders, L1-L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2-L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels.

C1-C2 intra-articular screw fixation for atlantoaxial posterior stabilization.

STUDY DESIGN: A trial of a new posterior stabilization technique for atlantoaxial instability and a report of preliminary results. OBJECTIVES: To describe a new posterior stabilization technique for atlantoxial instability. SUMMARY OF BACKGROUND DATA: Magerl's transarticular screw fixation is an accepted technique for rigid atlantoaxial stabilization, which reportedly has yielded many good clinical results. However, the technique is technically demanding and poses a risk of injury to the nerves and veins. METHODS: Eleven patients who had been treated with intra-articular screw fixation in combination with Halifax interlaminar clamp (OSTEONICS, Allendale, NJ) for atlantoaxial instability were observed. Results of their clinical examinations and biomechanical studies using resinous bones of a cervical spine model were reviewed. RESULTS: In all patients, occipital pain, neck pain, and neural deficit improved, and bony fusion with no correction loss was shown on radiography. To date, no vascular or neural complications have been found, and no instrumentation failures have occurred. In the biomechanical study, the Halifax with transarticular screw fixation had significantly greater flexion stiffness than the Halifax only or the Halifax with intra-articular screw fixation, but the torsion stiffness of the Halifax with intra-articular screw fixation was significantly greater than that of the other Halifax combinations. CONCLUSION: The preliminary results showed that this technique was effective in strengthening the rotational stability of the atlantoaxial fixation and was considered useful for atlantoaxial posterior stabilization.

Radiculopathy after laminoplasty of the cervical spine.

STUDY DESIGN: The risk factors of patients with and without radiculopathy after laminoplasty of the cervical spine were compared retrospectively. OBJECTIVES: To study the association between risk variables and postlaminoplastic radiculopathy to clarify the pathogenesis of radiculopathy and to devise preventive measures. SUMMARY OF BACKGROUND DATA: Radiculopathy after cervical laminoplasty on the expanded side has been attributed mainly to traumatic surgical techniques, whereas radiculopathy on the hinged side has been attributed to traction, tethering, or kinking of the nerve root that has resulted from posterior shift of the spinal cord from the preoperative position. There is still much divergence of opinion concerning the risk factors for the outbreak as well as the prevention. METHODS: Of 365 patients who had undergone laminoplasty, 20 patients (5.5%) developed postoperative radiculopathy. Using data from postoperative computed tomography scans and other sources, these patients were compared with 211 patients with no radiculopathy, who had undergone laminoplasty during the same period, to identify risk factors related to patient characteristics and surgical techniques. RESULTS: Of various risk factors studied, the narrowest level of the spinal canal, preoperative symptomatic severity, flatness of the spinal cord assessed by computed tomography myelography at C4-C5, cervical curvature, anterior protrusion of the superior articular process as assessed by computed tomography scan, laterality of the osteophytes, and ossification of the posterior longitudinal ligament could not significantly discriminate between patients with and without postoperative radiculopathy. The angle of lamina as measured by using computed tomography scans obtained after expansion in the patients with radiculopathy was greater than 68 degrees on the opened and hinged sides and was significantly greater than the angle in patients without radiculopathy (P < 0.05). The incidence of radiculopathy on both the opened and hinged sides was significantly higher in patients in whom the bony gutter had been cut on the lateral side of the medial aspect of the zygapophyseal joint. CONCLUSION: Any one of patients' characteristics could not be correlated with postoperative cervical radiculopathy in this study. To prevent postoperative radiculopathy, it may be important during surgery to place the bony gutter on the medial side of the zygapophyseal joint and to keep the slope of the opened lamina within 60 degrees.

Reconstruction using implants compatible with MRI for malignant spine tumors.

It is necessary to resect malignant spine tumors aggressively and to subsequently reconstruct the spinal column. The Diapason screw and hook system, which is compatible with magnetic resonance imaging, has been used recently for reconstruction. This study included 17 patients (5 with primary tumors and 12 with metastatic tumors) who underwent excision and reconstruction with the Diapason screw and hook system. The surgical procedures performed were circum-spinal decompression by posterior extensive curettage in 12 cases, and en bloc total spondylectomy in 5. The follow-up periods ranged from 6 to 28 months. Though paralyses of Frankel grade B in 2 patients were not improved, paralyses of Frankel grade C in 10 cases and Frankel grade D in 4 cases improved to Frankel grade D or better postoperatively. MRI was performed to detect recurrences during the follow-up period. Recurrence of paralysis occurred in 5 patients. MRI could disclose recurrences of tumors in these patients because there were fewer signal loss artifacts in these implants than are found in those made of stainless steel alloy. For detecting recurrences, the Diapason system was satisfactory in the MRI follow-ups.

Differences on intraoperative ultrasonography between meningioma and neurilemmoma.

We examined the differences on intraoperative ultrasonography between 17 cases of meningioma and 29 of neurilemmoma, the common intradural extramedullary tumors. In meningiomas, cysts were rarely seen (in 12.5%, P < 0.01%) and echogenicity was high (in 82.3%, P < 0.01%). In neurilemmoma, many cysts were seen (72.5%) and low echoes tended to be more common (72.4%, P < 0.01%). In the neurilemmomas with high or isoechogenicity, Antoni A types, histologically rich in collagen fibres, predominated.

Rigix plate system for anterior fixation of thoracolumbar vertebrae.

Only a few plate systems are available for anterior fixation of thoracolumbar vertebrae because of the difficulty in fastening a screw and a plate together. If the fixation is inadequate, the screws will become loose. The Rigix plate system consists of screws made of titanium alloy and a plate made of pure titanium. All screws used for internal fixation are screwed into the plate. This system permits the use of anchor screws, which facilitate exertion of force to compress the vertebral bodies together or to distract them from each other. In this study, Rigix plates were used in 24 patients (20 with burst fractures and 4 with metastatic tumors). In the 20 patients with fracture, internal fixation with a graft and a Rigix plate was performed after anterior decompression. In the four patients with malignant tumors, total spondylectomy was performed anteriorly and posteriorly, followed by implantation of a vertebral prosthesis, and then internal fixation with a Rigix plate combined posterior instrumentation with Diapson (Stryker Co., Tokyo, Japan) pedicular screws. Bone union was achieved in all patients. Neither breakage of instruments nor loosening of connections occurred in any case. In patients treated for bone metastases, the reconstructed spinal structure was able to be maintained for a long period. Of the screws used, five (5%) were not able to remain fixed as intended because they were inserted at inappropriate angles into the plate, but the fixation itself was excellent. Because of the low profile, ease of manipulation (mean instrumentation time was 25 min), and compatibility with magnetic resonance imaging, the Rigix plate is useful for anterior fixation of thoracolumbar vertebrae.

A randomized trial of cisplatin, vinblastine, and bleomycin versus cyclophosphamide, aclacinomycin, and cisplatin in epithelial ovarian cancer.

After primary cytoreductive surgery, a randomized clinical trial was conducted in women with epithelial ovarian cancer to compare the impact on survival between PVB chemotherapy, consisting of cisplatin, vinblastine and bleomycin, and CAP chemotherapy, consisting of cyclophosphamide, aclacinomycin and cisplatin. There were 148 evaluable patients. One hundred and five patients with stage II, III and IV were analyzed in this study, 49 of them received PVB chemotherapy while the remaining 56 patients received CAP chemotherapy. Sixty-four patients fulfilled the criteria for clinical remission set by the Tokai Ovarian Tumor Study Group [Gynecol Oncol 1993;48:342-348]. The remission rate was 73 and 50% in the PVB and CAP groups, respectively, and showed a significant advantage for the PVB group (p = 0.0139). Moreover, the recurrence rate was 44% in the PVB group and 61% in the CAP group after clinical remission, although there was no significant difference between the two groups. The final survival rate was 32% in the PVB group and 24% in the CAP group. There was a significant difference of survival rate between both groups at 24 months (p = 0.0378) and 48 months (p = 0.0450), but finally no significant difference was found at 96 months (p = 0.0660). Compared to the CAP regimen, the PVB combination has a significantly higher efficacy in remission, but there was no significant difference in the long-term survival rate. Furthermore, multivariate analysis demonstrated that the PVB chemotherapy improved the survival, but it was not significant. The authors conclude that PVB chemotherapy may be more effective than CAP chemotherapy for epithelial ovarian cancer.

Distribution of platinum in human gynecologic tissues and pelvic lymph nodes after administration of cisplatin.

BACKGROUND: Defining tissue accumulation of platinum may be of importance, since it may provide a pharmacological explanation for organ-specific cisplatin activity. This study was conducted to evaluate the efficacy of cisplatin at the tissue level in different gynecologic organs. The doses administered were equivalent to those used in neoadjuvant chemotherapy regimens. STUDY DESIGN: Cisplatin was administered intravenously to patients with cervical or endometrial cancer 1 h before operation, and platinum accumulations in tissues were assayed by the atomic absorption method. RESULTS: Platinum accumulation was highest in the cervix and next highest in the myometrium in both cancers. Platinum accumulation in ovary and lymph node was only 0.58 and 0.57 times that in the myometrium, respectively. In patients with cervical cancer, the platinum accumulations in the myometrium and cervix were significantly higher than in the ovary and lymph node. Platinum accumulation in cervical cancer tissue was lower than in the myometrium and cervix, suggesting that delivery of cisplatin to a cervical cancer is somewhat more difficult than to the normal cervix. In patients with endometrial cancer, there was significantly more accumulation in the cervix than in the ovary and lymph node. CONCLUSIONS: These data indicated that cisplatin was easily distributed to the cervix and myometrium, but not to the ovary, lymph node, and cancer tissues.

Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report.

STUDY DESIGN: Clinical testing of segmental pedicular screw hook fixation repairing defects in lumbar spondylolysis. OBJECTIVES: The authors tested segmental pedicular screw hook fixation using ISOLA implants (AcroMed Corp., Cleveland, OH) to maintain direct repair of the defect in pars interarticularis while fusion occurs. The device should not break while fusion takes place with out a postoperative body cast. SUMMARY OF BACKGROUND DATA: Previous techniques of direct repair of defects in lumbar spondylolysis have not been successful universally, and wire breakage has occurred despite the use of a postoperative body cast. METHODS: This technique stabilizes bone grafted to the detect by a pedicular screw, a hook, and a rod used in combination. Six patients with lumbar spondylolysis were treated by means of this technique. RESULTS: Postoperatively, all patients with low back pain or radicular pain experienced significant relief. Radiographs, including lateral flexion-extension radiographs and tomograms, showed five patients to have a bilateral union and one a unilateral union, and none of the instrumentation failed. CONCLUSION: This technique is considered useful for direct repair of the defects found in lumbar spondylolysis.

Clinical value of CA125, CA19-9, CEA, CA72-4, and TPA in borderline ovarian tumor.

Five tumor markers were analyzed clinically in 101 patients with borderline ovarian tumors who were treated by the Tokai Ovarian Tumor Study Group, an association comprising Nagoya University and its affiliated hospital, between January 1986 and December 1994. The positive rate of CA125 was 68.2% in serous tumor and 51.9% in mucinous tumor. The positive rate of CA19-9 was 51.5% in serous tumor and 44.7% in mucinous tumor. The positive rates and mean serum levels of CA125 in serous and mucinous tumor by stage had rising tendencies with an increase in each stage. The mean serum levels of CA19-9 in serous and mucinous tumor by stage had rising tendencies with an increase in each stage. CA125 and CA19-9 were useful for screening of borderline ovarian tumors. The positive rates of CEA and TPA in mucinous tumor were 32.5 and 27.3%, respectively, although none of the patients with serous tumor were positive in CEA and TPA. The positive rates and mean serum levels of CEA in mucinous tumor by stage had rising tendencies with an increase in each stage. The positive rate of CA72-4 was significantly lower than that of CA125 (P < 0.05).

Clinical application of the Diapason hook system: a preliminary case report.

A preliminary case report of the clinical application of the Diapason hook system is discussed. The hooks were implanted in six patients for the fixation of the thoracic region (n = 3), the prevention of backout of pedicular screws (n = 3), and repair of the pars interarticularis (n = 1); the patients were followed for more than 6 months after the surgery. Results indicate that in all of the cases the initial purpose of the Diapason hook system was served. The advantages of the Diapason screw and hook system are its titanium alloy material and simplicity in implanting. Although there have been no instrument failures or any other complications, the cases need longer follow-up. In addition, the size of some hooks needs to be improved because they were too large to apply to the short segments.

[The indication of operative procedure for a metastatic spine tumor: a scoring system for the preoperative evaluation of the prognosis].

Since 1987, the operative procedure for a metastatic spine tumor has been decided on the basis of a scoring system for the preoperative evaluation of prognosis. Six parameters which affected the prognosis were employed in this assessment: 1) the general condition, 2) the number of extraspinal bone metastases, 3) the number of metastases in the vertebral body, 4) incidence of metastasis to a major internal organ (lungs, liver, kidneys, and/or brain), 5) the primary site of the cancer, and 6) the severity of spinal cord palsy. Each parameter was scored from 0 (high risk) to 2 (low risk) points. An excisional operation was performed when the total score was above 9 points, while a palliative operation was indicated for those who scored under 5 points. This assessment system was evaluated for 113 cases who had undergone surgery according to this criterion. The survival period of 92.3% of patients who scored less than 6 points was less than 6 months, while that of 78.3% of patients who scored more than 8 points was more than one year. The total score obtained for each patient correlated with the prognosis, and was valuable in predicting prognosis for a lesion at any stage. In conclusion, it was appropriate to indicate the operative procedure for a metastatic spine tumor according to this scoring system.

Evaluation of clinical lumbar instability using the treadmill.

The physical signs of lumbar instability have not yet been clearly defined. Furthermore, they do not always coincide with the abnormal movement on flexion-extension radiographs. Thus, the treadmill was used to evaluate clinical lumbar instability. The subjects were 82 patients with degenerative lumbar disease aggravated by walking or daily physical activities. The reproduction and provocation of low-back pain or pain in the lower extremities was examined during walking on a treadmill. The responses of the reproduction and provocation of the symptoms were divided into four grades. Fifteen cases were examined again using a treadmill after body casting to determine the indication for fusion surgery. As a result, the responses in the reproduction or provocation test using a treadmill manifest more dominant reflection of clinical symptoms suggesting clinical lumbar instability than the existence of the abnormal movement on flexion-extension radiographs. Reexamination after body casting was useful to determine the indications of fusion operations. The reproduction or provocation test using a treadmill was implied as a possible functional evaluation method of clinical lumbar instability.

Penetration of a screw into the thoracic aorta in anterior spinal instrumentation. A case report.

With recent advances in spine surgery, spinal instrumentation has allowed the introduction of varied new devices and techniques, expanding its potentials. Yet this has also led to the incidence of unexpected complications. The current article reports on a serious case the authors recently experienced, in which a screw used for the instrumentation of the thoracic vertebra penetrated the aorta.

Clinical values of intraoperative ultrasonography for spinal tumors.

Intraoperative ultrasonography was conducted in 52 cases of spinal tumor, at 7.5 MHz, mainly by means of linear scanning, to evaluate its clinical usefulness. The procedure was effectively applied in such clinical purposes as: 1) locating the tumor, 2) deciding the resectability of intramedullary tumors, 3) deciding the site for intraspinal biopsy or shunt tube insertion, 4) establishing the topical relationship between the spinal cord and the tumor, and 5) differentiating neurilemoma from meningoma. Of 10 patients with intramedullary tumors, 5 (50%) were removed, because extirpation was possible when the spinal cord and the tumor were well demarcated on the ultrasonogram. Intratumorous cysts were found to exist in 73% of neurilemoma and 14% of meningioma cases, enabling the differential diagnosis between the two tumors. Intraoperative ultrasonography is an uninvasive method to reveal intradural and extradural conditions and thus constitutes a valuable diagnostic means to ensure safe and precise spinal surgery.