Incomplete Atypical Femoral Fracture With Severe Bowing Treated by Intramedullary Nail and Corrective Osteotomy.

We present the case of an 82-year-old female who had difficulty walking due to right thigh pain caused by incomplete atypical femoral fracture (AFF). The femoral bowing was so severe that intramedullary nail insertion was impossible, so we performed a corrective osteotomy of the femur and inserted the intramedullary nail. Postoperatively, the femoral pain disappeared, and bone fusion was achieved at one year and two months postoperatively. In cases of incomplete AFF with very severe femoral bowing, internal fixation with an intramedullary nail combined with corrective osteotomy of the femur is useful.

Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial.

Importance: Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. Objective: To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. Design, Setting, and Participants: This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. Interventions: Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. Main Outcomes and Measures: The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. Results: Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. Conclusions and Relevance: This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. Trial Registration: Identifier: UMIN000030929.

Risk factors for deep surgical site infection after posterior cervical spine surgery in adults: a multicentre observational cohort study.

Surgical site infection (SSI) is a serious complication following spine surgery and is correlated with significant morbidities, poor clinical outcomes, and increased healthcare costs. Accurately identifying risk factors can help develop strategies to reduce this devastating consequence; however, few multicentre studies have investigated risk factors for SSI following posterior cervical spine surgeries. Between July 2010 and June 2015, we performed an observational cohort study on deep SSI in adult patients who underwent posterior cervical spine surgery at 10 research hospitals. Detailed patient- and procedure-specific potential risk variables were prospectively recorded using a standardised data collection chart and were reviewed retrospectively. Among the 2184 consecutive adult patients enrolled, 28 (1.3%) developed postoperative deep SSI. Multivariable regression analysis revealed 2 statistically significant independent risk factors: occipitocervical surgery (P < 0.001) and male sex (P = 0.024). Subgroup analysis demonstrated that occipitocervical surgery (P = 0.001) was the sole independent risk factor for deep SSI in patients with instrumented fusion. Occipitocervical surgery is a relatively rare procedure; therefore, our findings were based on a large cohort acquired using a multicentre study. To the best of our knowledge, this is the first study to identify occipitocervical procedure as an independent risk variable for deep SSI after spinal surgery.

Electron beam intraoperative radiotherapy for metastatic epidural spinal cord compression: a prospective observational study.

To assess the additional effects of intraoperative radiotherapy (IORT) with decompression surgery and adjuvant external beam radiotherapy (EBRT) for metastatic epidural spinal cord compression (MESCC). This single-arm institutional prospective observational study recruited patients between June 2017 and March 2020 and included those with symptoms of spinal cord compression owing to metastases, who were diagnosed using MRI. Patients with radiation-sensitive primary tumors and those who could not tolerate surgery were excluded. The treatment protocol comprised decompression surgery and electron beam IORT of 20 Gy in a single fraction followed by EBRT of 30 Gy in 10 fractions. The primary endpoints included the 1-year local failure rate and ambulatory functions. The study was closed in May 2019 owing to changes in treatment policies at our institution. Twenty patients were registered between June 2017 and May 2019. Although all patients completed surgery and IORT, 2 did not receive postoperative EBRT. Patients most commonly had colorectal cancer (4 patients), followed by thyroid cancer, renal cell carcinoma, lung cancer, breast cancer, sarcomas, and other cancers (3, 3, 2, 2, 2, and 4 patients, respectively). The median follow-up duration was 16 months (range 2-30 months); the 1-year local failure rate was 16%. On comparing ambulatory functions pre-treatment and at 1 year after treatment, improvement, no change, and worsening were observed in 3, 9, and 0 patients, respectively. This study's findings suggest that decompression surgery and IORT followed by EBRT are effective in achieving local control and maintaining ambulation in patients with MESCC.

Risk factors for deep surgical site infection following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine: a multicenter, observational cohort study of 2913 consecutive cases.

PURPOSE: Surgical site infection (SSI) is one of the most devastating complications following spinal instrumented fusion surgeries because it may lead to a significant increase in morbidity, mortality, and poor clinical outcomes. Identifying the risk factors for SSI can help in developing strategies to reduce its occurrence. However, data on the risk factors for SSI in degenerative diseases are limited. This study aimed to identify risk factors for deep SSI following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine in adult patients. METHODS: This was a multicenter, observational cohort study conducted at 10 study hospitals between July 2010 and June 2015. The subjects were consecutive adult patients who underwent posterior instrumented fusion surgery for degenerative diseases in the thoracic and/or lumbar spine and developed SSI. Detailed patient-specific and procedure-specific potential risk variables were prospectively recorded using a standardized data collection chart and retrospectively reviewed. RESULTS: Of the 2913 enrolled patients, 35 developed postoperative deep SSI (1.2%). Multivariable regression analysis identified three independent risk factors: male sex (P = 0.002) and American Society of Anesthesiologists (ASA) score of ≥ 3 (P = 0.003) as patient-specific risk factors, and operation including the thoracic spine (P = 0.018) as a procedure-specific risk factor. CONCLUSION: Thoracic spinal surgery, an ASA score of ≥ 3, and male sex were risk factors for deep SSI after routine thoracolumbar instrumented fusion surgeries for degenerative diseases. Awareness of these risk factors can enable surgeons to develop a more appropriate management plan and provide better patient counseling.

Incidence of Unrecognized Incidental Durotomy during Surgery for Malignant Spinal Tumor.

INTRODUCTION: Cerebral spinal fluid leak from durotomy is a well-known risk with spinal surgeries. The aim of this study is to identify the incidence of unrecognized incidental durotomy during posterior surgery for spinal metastases and its risk factors. METHODS: Participants comprised 75 patients who underwent posterior spine surgery for spinal metastases between January 2012 and December 2016. Cases with apparent durotomy noticed intraoperatively were excluded. Unrecognized durotomy was diagnosed as the presence of wide subcutaneous fluid retention on magnetic resonance imaging at least 3 months postoperatively. For comparison, 50 patients who underwent cervical laminoplasty due to cervical spondylotic myelopathy were examined using the same method. We also examined correlations between occurrence of durotomy and patient characteristics such as age, type of tumor, location of tumor (ventral or dorsal), extent of tumor, and history of radiotherapy before surgery. RESULTS: Unrecognized durotomy occurred in 21 cases of spinal metastasis (26.7%) and in 1 case of cervical spondylotic myelopathy (2%), representing a significant difference between groups. Age, type of tumor, location of tumor, extent of tumor, and history of radiotherapy before surgery did not correlate significantly with occurrence of durotomy. No local trouble was observed in durotomy cases, except in one case with subcutaneous local infection. CONCLUSIONS: The incidence of unrecognized incidental durotomy is significantly higher during surgery for spinal metastases than that during surgery for degenerative disease.

A sliding scale to predict postoperative complications undergoing posterior spine surgery.

BACKGROUND: There is a lack of consensus of operative time (OT) and estimated blood loss (EBL) for elderly patients based on the predicted risk of complications after posterior spine surgery. The purpose of this study was to evaluate the effect of age, OT, and EBL on the postoperative complication risk and to develop a simple sliding scale. METHODS: We explored prospectively collected data of consecutive patients who underwent posterior spine surgery in seven tertiary referral hospitals from November 2013 to May 2016. Age (<70, 70-74, 75-79, 80-84, ≥85 years), OT (<2, 2-<3, 3-<4, 4-<5, ≥5 h), and EBL (<500, 500-<1000, 1000-<1500, 1500-<2000, ≥2000 ml) were categorized ranging from 1 (lowest) to 5 (highest). The association between the crude cumulative categories' number and the incidence of complications was analyzed. We further evaluated the association by re-categorizing the cumulative number into three groups (3-4, 5-10, ≥11). RESULTS: Total of 2416 patients (median age: 70 years old) were enrolled and major complications were observed in 75 (3.1%) patients. Age, OT, and EBL showed similar odds ratio (1.18-1.19) as each category increased. The cumulative categories' number fitted the estimate complication risk (Hosmer-Lemeshow P = 0.87), and statistically significant trend was observed between predicted and actual complication rates (Cochran-Armitage test, P < 0.001). When cumulative categories' numbers were stratified into three groups, significant increasing trend of risk were observed (Mantel-Haenszel P < 0.001). Based on the categorical numbers, we proposed a simple sliding scale. CONCLUSION: Our data indicated that the risk of postoperative complication was associated with cumulative score based on increased age, OT, and EBL. A simple sliding scale was developed based on these factors, which may be useful to predict complication risk after posterior spine surgery.

Association Between Normothermia at the End of Surgery and Postoperative Complications Following Orthopedic Surgery.

BACKGROUND: Maintaining perioperative normothermia is recommended by recent guidelines for the prevention of surgical site infections (SSIs). However, the majority of supporting data originates outside the field of orthopaedic surgery. METHODS: The effect of normothermia was explored using the prospectively collected data of consecutive patients who underwent single-site surgery in 7 tertiary referral hospitals between November 2013 and July 2016. SSIs, urinary tract infections (UTIs), respiratory tract infections (RTIs), cardiac and cerebral events (CCE), and all-cause mortality rates within 30 days after surgery were compared between patients with normothermia (body temperature ≥36°C) and those with hypothermia (<36°C) at the end of surgery, after closure. Multivariable adjusted and inverse-probability weighted regression analyses were performed. RESULTS: The final cohort included 8841 patients. Of these, 11.4% (n = 1008) were hypothermic. More than 96% were evaluated in person by the physicians. After adjusting for multiple covariates, normothermia was not significantly associated with SSIs (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI] 0.59-2.33), UTIs (aOR 1.14, 95% CI 0.66-1.95), RTIs (aOR 0.60, 95% CI 0.31-1.19), or CCE (aOR 0.53, 95% CI 0.26-1.09). In contrast, normothermia was associated with a lower risk of 30-day mortality (aOR 0.26, 95% CI 0.11-0.64; P < .01; weighted hazard ratio 0.21, 95% CI 0.07-0.68; P = .002). In a subgroup analysis, normothermia was associated with reduced mortality in all types of surgical procedures. CONCLUSIONS: Whereas our findings suggest no clear association with SSI risks following orthopedic surgery, our study supports maintaining perioperative normothermia, as it is associated with reduced 30-day mortality.

Risk Factor Analysis of Deep Surgical Site Infection After Posterior Instrumented Fusion Surgery for Spinal Trauma: A Multicenter Observational Study.

BACKGROUND: Surgical site infection (SSI) is a dire complication in spinal surgeries, resulting in reoperation, prolonged hospitalization, and increased expenses. Patients with traumatized spine have been reported to have a high risk of postoperative SSI. Precise identification of risk factors associated with SSI can be helpful in its prevention. However, there are only a limited number of studies investigating risk factors of SSI after posterior instrumented fusion for traumatized spine. METHODS: From July 2010 to June 2015, we conducted an observational study on deep SSI after posterior instrumented fusion surgery for spinal trauma in adult patients at 10 research hospitals. Detailed clinical data were prospectively collected using a standardized data collection chart and were retrospectively analyzed. SSI was diagnosed based on the definition by the Centers for Disease Control and Prevention. RESULTS: A total of 623 consecutive adult patients were enrolled in this study, of which 20 (3.2%) developed deep SSI. According to multivariate regression analysis, surgery at academic hospitals (P = 0.004) and an American Society of Anesthesiologists (ASA) score ≥3 (P = 0.017) were independent predictors of deep SSI after posterior instrumented fusion surgery for spinal trauma. CONCLUSIONS: The complexity of patients and resident involvement in surgeries may be greater at academic than at nonacademic hospitals. ASA score can be considered as an accessible and comprehensive tool for surgeons to preoperatively gauge the potential risk of SSI, a complex clinical entity. The results of this study can improve clinicians' risk perception in those undergoing posterior fusion for spinal trauma.

Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: A prospective multicenter surveillance study with registry of 4027 cases.

Surgical site infection (SSI) is a significant complication after spinal surgery and is associated with increased hospital length of stay, high healthcare costs, and poor patient outcomes. Accurate identification of risk factors is essential to develop strategies to prevent wound infections. The aim of this prospective multicenter study was to determine the independent factors associated with SSI in posterior lumbar surgeries without fusion (laminectomy and/or herniotomy) for degenerative diseases in adult patients. From July 2010 to June 2014, we conducted a prospective multicenter surveillance study in adult patients who developed SSI after undergoing lumbar laminectomy and/or discectomy in ten participating hospitals. Detailed patient and operative characteristics were prospectively recorded using a standardized data collection format. SSI was based on the Centers for Disease Control and Prevention definition. A total of 4027 consecutive adult patients were enrolled, of which 26 (0.65%) developed postoperative SSI. Multivariate regression analysis indicated two independent factors. An operating time >2 h (P = 0.0095) was a statistically significant independent risk factor, whereas endoscopic tubular surgery (P = 0.040) was a significant independent protective factor. Identification of these associated factors may contribute to surgeons' awareness of the risk factors for SSI and could help counsel the patients on the risks associated with lumbar laminectomy and/or discectomy. Furthermore, this study's findings could be used to develop protocols to decrease SSI risk. To the best of our knowledge, this is the first prospective multicenter study that identified endoscopic tubular surgery as an independent protective factor against SSI after lumbar posterior surgery without fusion.

Does intrawound vancomycin powder reduce surgical site infection after posterior instrumented spinal surgery? A propensity score-matched analysis.

BACKGROUND CONTEXT: Recent reports suggested that placing vancomycin powder into surgical wounds before closure can prevent surgical site infections (SSIs) in spinal surgery. PURPOSE: The present study aimed to evaluate if intrawound vancomycin powder could prevent SSIs after spinal surgery with posterior instrumentation. STUDY DESIGN: This is a multicenter retrospective cohort study using propensity score matching. PATIENT SAMPLE: We reviewed all spinal surgeries performed with posterior instrumentation from July 2012 to December 2014 at 11 institutions among patients aged ≥15 years. OUTCOME MEASURES: The incidence of SSIs was compared between patients who received intrawound vancomycin powder (vancomycin group) and those who did not (control group). METHODS: Demographic and operative data and microbiological findings of SSI cases were analyzed. After a preliminary whole-cohort analysis, we performed one-to-one propensity score matching to adjust for the differences between the two groups and then compared the incidence of SSIs between the matched groups. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. RESULTS: A total of 2,859 patients were included in the study. In the vancomycin and control groups (n=694 and n=2165, respectively), 12 (1.73%) and 21 (0.97%) patients developed SSIs, respectively, but the difference was not statistically significant (p=.10, chi-square test). During the propensity score-matched analysis, 507 pairs were analyzed. No significant change in the rate of SSIs was seen between the vancomycin and control groups (8 SSIs [1.58%] vs. 9 SSIs [1.78%], respectively; p=.81, chi-square test). Microbiological analysis revealed that 5 of 12 (42%) and 11 of 21 (52%) SSIs in the vancomycin and control groups, respectively, were caused by Staphylococcus (p=.72, Fisher exact test). CONCLUSIONS: Intrawound application of vancomycin powder was not associated with a significant decrease in the incidence of SSIs after posterior instrumented spinal surgeries in a propensity score-matched analysis. However, the rate of infections caused by Staphylococcus species was lower in the vancomycin group.

The significance of spinal fixation in palliative surgery for spinal metastases.

The purpose of this study is to assess appropriate fixation methods for surgical spinal stabilization for spinal metastases. 191 patients who underwent spine surgery for spinal metastases are included in this study. The surgeries included 1) posterior decompression only (29), 2) posterior decompression and fixation (153), and 3) decompression and circumferential fixation (9). We evaluated and compared all cases based upon 1) use of fixation, 2) number of levels included in the fixation, 3) type of fixation, 4) use of bone graft, 5) presence of preoperative collapse of involved vertebrae, and 6) involved area of vertebrae according to Kostuik classification. Progression of vertebral collapse on radiographs or Magnetic Resonance Imaging (MRI) or occurrence of implant failure after surgery was considered a failed case. The number of failed cases was 51 (27%). The factors that were compared between the failed and successful groups were: use of fixation (p < .01), extent of fixation (one level above and one level below affected vertebrae vs. ≧ two above and two below, p < .01), presence of preoperative collapse of affected vertebrae (p < .05), and ≧ four of six columns of vertebral involvement according to Kostuik classification (p < .01). All results were statistically significant. In conclusion, when treating metastatic spinal disease with instability, it is recommended that posterior fixation with instrumentation be used and extend at least two levels above and two below the affected vertebrae. Preoperative collapse of affected vertebrae and greater involvement of the vertebrae with metastatic disease results in greater local instability.

Risk factors for incidental durotomy during posterior open spine surgery for degenerative diseases in adults: A multicenter observational study.

Incidental durotomy (ID) is a common intraoperative complication of spine surgery. It can lead to persistent cerebrospinal fluid leakage, which may cause serious complications, including severe headache, pseudomeningocele formation, nerve root entrapment, and intracranial hemorrhage. As a result, it contributes to higher healthcare costs and poor patient outcomes. The purpose of this study was to clarify the independent risk factors that can cause ID during posterior open spine surgery for degenerative diseases in adults. We conducted a prospective multicenter study of adult patients who underwent posterior open spine surgery for degenerative diseases at 10 participating hospitals from July 2010 to June 2013. A total of 4,652 consecutive patients were enrolled. We evaluated potential risk factors, including age, sex, body mass index, American Society of Anesthesiologists physical status classification, the presence of diabetes mellitus, the use of hemodialysis, smoking status, steroid intake, location of the surgery, type of operative procedure, and past surgical history in the operated area. A multivariate logistic regression analysis was performed to identify the risk factors associated with ID. The incidence of ID was 8.2% (380/4,652). Corrective vertebral osteotomy and revision surgery were identified as independent risk factors for ID, while cervical surgery and discectomy were identified as factors that independently protected against ID during posterior open spine surgery for degenerative diseases in adults. Therefore, we identified 2 independent risk factors for and 2 protective factors against ID. These results may contribute to making surgeons aware of the risk factors for ID and can be used to counsel patients on the risks and complications associated with open spine surgery.

White Blood Cell Count and C-Reactive Protein Variations After Posterior Surgery With Intraoperative Radiotherapy for Spinal Metastasis.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To evaluate the feasibility of blood test parameters [white blood cell (WBC) count and C-reactive protein (CRP)] for predicting and diagnosing postoperative infection after posterior surgery with intraoperative radiotherapy (IORT) for spinal metastasis. SUMMARY OF BACKGROUND DATA: Posterior surgery with IORT is effective for treating spinal metastasis, as we previously reported. However, the procedure requires that the patient be transferred from the operating room to the irradiation room. In addition, the patient's general status is often poor, and the risk of postoperative infection is high. MATERIALS AND METHODS: A total of 279 patients who underwent IORT for the treatment of spinal metastasis between August 2004 and June 2013 were included in this study. The WBC count (/10 µL) and CRP level (mg/dL) were recorded in all patients preoperatively and on alternative days for up to 7 days after surgery. We assessed the development of surgical-site infection (SSI) for up to 1 month after surgery. RESULTS: SSI occurred in 41 patients (14.7%). The preoperative WBC count and CRP level did not differ between the infected and noninfected patients. The WBC counts on postoperative day (POD) 1 and POD 7 and the CRP levels on POD 7 were significantly higher in the infected patients (8.8 vs. 10.0, P=0.04; 6.1 vs. 8.8, P=0.002; 3.89 vs. 9.50, P<0.001). A receiver-operating characteristic curve analysis of the WBC count and CRP level for detecting SSI showed cutoff values of 9.6 (WBC count, POD 1), 6.5 (WBC count, POD 7), and 5.0 (CRP level, POD 7). CONCLUSIONS: A high WBC count and CRP level on POD 7 may be used to predict or detect SSI. In particular, a CRP level of 5.0 mg/dL on POD 7 strongly suggests the future development of SSI (sensitivity: 78%, specificity: 74%).

Occurrence of sudden paraplegia during follow-up period of thoracic vertebral compression fracture in a case with spinal epidural lipomatosis.

INTRODUCTION: Spinal epidural lipomatosis (SEL) involves hypertrophy of fat tissue in the extradural space, often associated with long-term corticosteroid therapy. Sometimes it causes severe spinal cord compression and the patient gradually becomes symptomatic. However, sudden onset of neurological deterioration is extremely rare. CASE PRESENTATION: We herein present a case of sudden paraplegia in a patient with thoracic SEL at 2 months after thoracic vertebral fracture, whose symptoms were consistent with a lesion at the same level as the SEL. Computed tomography scan showed no remarkable change in the degree of vertebral fracture at the time of neurological deterioration. We performed immediate decompression surgery and found hemorrhage and granulation tissue at the level of the fracture and removed it with the epidural fat tissue. The hematoma and granulation tissue were thought to be the cause of the acute deterioration. The patient recovered gradually from the paraplegia. DISCUSSION: Sudden paraplegia with SEL at the time of vertebral fracture has previously been reported, but this is the first report of SEL with delayed onset of paraplegia after an initial diagnosis of coexisting vertebral fracture.

Risk factors for surgical site infection after posterior fixation surgery and intraoperative radiotherapy for spinal metastases.

PURPOSE: Posterior surgery with intraoperative radiotherapy for spinal metastases offers effective therapy, as we have reported previously. However, the procedure involves transfer from the operating room to the radiotherapy room, and as these patients are somewhat immunocompromised, the risk of postoperative surgical site infection (SSI) may be increased. The aim of our study was to identify risk factors and patient characteristics associated with postoperative SSI following posterior fixation surgery and intraoperative radiotherapy for spinal metastases. METHODS: Participants comprised 279 patients who underwent IORT for the treatment of spinal metastases between August 2004 and June 2013. Patients who suffered SSI within 1 month after surgery were categorized as infected, and all others were categorized as non-infected. We compared factors of age, sex, use of pre-operative corticosteroid, medical history of diabetes, prognosis scores (Tomita, Tokuhashi, and Katagiri), pre- and postoperative Frankel scale scores, site of tumor origin, administration of pre-operative radiotherapy, operation time, intraoperative blood loss, intraoperative irradiation dose, and pre- and postoperative performance status between groups. RESULTS: SSI occurred in 41 patients (14.7%). Katagiri's and Tokuhashi's prognostic scores (P < 0.05 each), postoperative Frankel scale score (P < 0.01), administration of pre-operative radiotherapy (P < 0.05), and postoperative performance status (P < 0.05) all correlated significantly with occurrence of SSI. Multivariate analysis using those factors revealed administration of pre-operative radiotherapy as a factor independently associated with SSI (P < 0.05). CONCLUSIONS: Patient prognosis, postoperative ambulatory function, and pre-operative radiotherapy were risk factors for SSI in patients with spinal metastases. Duration of surgery and intraoperative blood loss were not associated with occurrence of SSI.

META: an MRI-based scoring system differentiating metastatic from osteoporotic vertebral fractures.

BACKGROUND CONTEXT: Magnetic resonance imaging (MRI) is useful for the differential diagnosis of osteoporotic vertebral fractures (OVFs) and metastatic vertebral fractures (MVFs), but no single finding is absolutely conclusive. PURPOSE: The purpose of the present study was to create a scoring system to facilitate the correct diagnosis of MVFs by integrating several MRI findings. STUDY DESIGN: This is a retrospective and single-center observational study that attempts to create a diagnostic scoring system by discriminant analysis. PATIENTS SAMPLE: We included 100 OVFs and 100 MVFs in thoracolumbar vertebrae of which MR images were obtained within 60 days from the suspected time of fractures. OUTCOME MEASURES: The sensitivity and specificity of known important MRI findings were assessed, and the classification accuracy of the scoring system was investigated. METHODS: Seven MRI findings of these fractures were analyzed to evaluate their sensitivity and specificity. Using these findings as variables, discriminant analysis was performed in 140 fractures as a training set, and the classification accuracy was calculated in the remaining 60 fractures as a test set. Additionally, the images of these 60 fractures were reviewed by another blinded reviewer to investigate the interobserver reliability of each finding. RESULTS: All findings had high specificity with low-to-moderate sensitivity. Eight variables were selected in the final discriminant function. A simpler scoring system (MRI Evaluation Totalizing Assessment [META]) was created by approximating the coefficients and the constant term by integral numbers. The classification accuracy was calculated to be 96.6% in the test set. The interobserver reliability of the key findings varied, but the final discrimination conducted by META had the high agreement between the two reviewers (κ=0.93). CONCLUSIONS: This novel scoring system, META, could prove to be a useful tool for the differential diagnosis of OVFs and MVFs. It is simple and physician friendly, yet highly accurate.

Antibiotic-impregnated cement embedding technique for spinal instrumentation infections.

BACKGROUND AND STUDY AIMS: When surgical site infection occurs in patients with an instrumented spine, the management of infection is challenging because a biofilm is formed around the metallic surface of the implant. Although a wide variety of methods to salvage implants has been developed, previously reported methods reduce the patients' quality of life and are frequently time consuming and costly. PATIENTS AND METHODS: We performed a cement embedding technique in 13 consecutive patients with infection after spinal instrumentation. After meticulous open débridement, the metallic implants were embedded using polymethylmethacrylate (PMMA) mixed with antibiotics. Antibiotics were selected in each case according to the pathogens and their sensitivity. The wound was primarily closed. We did not restrict the patients' activity postoperatively. The implants were not removed unless it was necessary for further procedures. RESULTS: Nine patients, including those infected by methicillin-resistant Staphylococcus aureus (MRSA), were cured by débridement and PMMA embedding followed by systemic antibiotic treatment. No complications were reported. CONCLUSIONS: The antibiotic-impregnated PMMA embedding technique is an effective method for the treatment of spinal instrumentation infections. It is easy to perform and is also effective for MRSA infection.

Optimal schedule of preoperative embolization for spinal metastasis surgery.

STUDY DESIGN: A retrospective study. OBJECTIVE: To investigate the relationship between intraoperative blood loss during spinal metastasis surgery and the surgical delay after preoperative embolization. SUMMARY OF BACKGROUND DATA: Delaying surgery after embolization is thought to diminish its effectiveness because of revascularization, but there has been no scientific study that supports this hypothesis. METHODS: We reviewed data from 66 consecutive posterior palliative decompression surgical procedures for spinal metastasis from thyroid and renal cell carcinoma (39 thyroid and 27 renal) in 58 patients between 2004 and 2012. All patients underwent preoperative angiography. The timing of preoperative embolization was determined on the basis of the operating room and interventional radiologist schedules. Excluding one case who did not receive embolization due to lack of hypervascularity, we analyzed 65 cases to compare intraoperative blood loss according to the completeness of embolization and the time lapse between embolization and surgery. RESULTS: Surgical procedures were performed on the same day of embolization in 21 cases (same day-group), and on the next day after embolization in 39 cases (next-day group). Five surgical procedures were performed 2 days later. The intraoperative blood loss was significantly lesser with complete embolization than with partial embolization (mean ± standard deviation: 809 ± 835 vs. 1210 ± 904 mL, P = 0.03). Among those with complete embolization, the intraoperative blood loss as well as the perioperative transfusion requirement was significantly lesser in the same-day group than in the next-day group (mean ± standard deviation: blood loss: 433 ± 376 vs. 1012 ± 974 mL, P = 0.01; transfusion requirement: 1.5 ± 1.7 vs. 4.2 ± 4.1 units, P = 0.04). CONCLUSION: Preoperative embolization showed greater effectiveness in reducing intraoperative blood loss when surgery for spinal metastasis was performed on the same day than when surgery was delayed. Surgery should be performed on the same day of embolization if possible. LEVEL OF EVIDENCE: 4.