Risk factors for poor outcomes of early rehabilitation after total en bloc spondylectomy: a retrospective chart review of 140 patients.

STUDY DESIGN: A retrospective chart review. OBJECTIVES: Total en bloc spondylectomy (TES) has been reported to decrease the rate of local recurrence and increase survival. Although it is important to achieve early recovery of physical functions after surgery, no studies have evaluated rehabilitation outcomes during the acute phase after TES. This study evaluated ambulatory functions and activities of daily living (ADLs) after surgery and analyzed the prognostic significance of variables affecting rehabilitation outcomes at 1 month after TES. SETTING: University hospital in Kanazawa, Japan. METHODS: This study included 140 patients with spinal tumors who underwent TES between April 2010 and April 2017. Demographic characteristics, neurological functions, perioperative complications functional status as measured by the Functional Independent Measure, and independent indoor walking based on the Spinal Cord Independent Measure were extracted from medical records. Multivariate analyses were performed to assess factors associated with the recovery of ambulation and ADL at 1 month after TES. RESULTS: Preoperative neurological deficits were observed in 51 patients (36%), and postoperative neurological deterioration was found in 41 patients (29%). Multivariate analyses indicated that preoperative neurological deficits (odds ratio [OR], 5.23; 95% confidence interval [CI], 2.07-15.99), postoperative cerebrospinal fluid leakage (OR, 13.42; 95% CI, 2.93-78.82), surgical site infections (OR, 15.27; 95% CI, 2.26-127.7), and postoperative neurological deterioration (OR, 4.86; 95% CI, 1.33-19.99) were risk factors for walking ability and recovery of ADL (P < 0.01). CONCLUSIONS: This study identified preoperative neurological dysfunction and perioperative complications as independent risk factors for poor recovery of ambulation and ADL early after TES.

Characteristics and functional outcomes of chordoma patients admitted for inpatient rehabilitation.

PURPOSE: To describe the population and functional changes observed after an inpatient rehabilitation facility stay in chordoma patients Materials and Methods: We conducted a consecutive series retrospective review of patients with chordoma, admitted to an academic inpatient rehabilitation facility after surgical resection from 2010 to 2015. Information regarding demographic, tumor- and surgery-specific data, lengths of stay, complications, admission and discharge functional independence measure scores was collected. RESULTS: A total of 40 patients with a diagnosis of chordoma were admitted to an inpatient rehabilitation facility postoperatively were included for analysis. Thirty-three patients had initial resection of chordoma, seven patients had resection of recurrent chordoma, and eight patients had metastatic disease on admission to an inpatient rehabilitation facility. The average change in total and motor functional independence measure scores after an inpatient rehabilitation facility stay was 33.7 and 26.1, respectively. The acute hospital transfer rate was 32.5% and the postoperative complication rate was 62.5%. CONCLUSIONS: This study is the first to describe the population and functional improvement in the chordoma population who are admitted to an inpatient rehabilitation facility postoperatively. While there is a high rate of acute hospital transfer and postoperative complications, these values are comparable to prior studies in this population. With the increasing prevalence of cancer survivors, improving function during and after cancer treatment is extremely important. Implications for Rehabilitation Chordoma patients who are admitted to inpatient rehabilitation facilities after surgical tumor resection experience improvement in multiple functional domains. Chordoma patients admitted to inpatient rehabilitation facilities experience a high rate of acute hospital transfer, but it is comparable to other cancer rehabilitation populations. Understanding the characteristics of the postoperative chordoma population is essential to direct future studies regarding cancer rehabilitation.

[Comprehensive assessment of the outcomes of surgical treatment of patients with metastatic spinal cord injuries].

INTRODUCTION: Every year the number of cancer patients increases due to increased life expectancy. According to various sources, metastases in the spine are found during autopsy in 30-90% of patients with a history of cancer. So far, there have been no full-scale studies of the quality of life of patients with various metastatic tumors of the spine who underwent surgical treatment in Russian literature. The main objective of this study was to demonstrate the need for implementing the comprehensive treatment of patients with metastases in the spine and target setting as the main tool to identify the factors that adversely affect the patients' quality of life. MATERIAL AND METHODS: The quality of life of 56 patients aged 16 to 81 years was assessed, including 26 males and 30 females. Twenty-six patients underwent surgical treatment between 2002 and 2009, and thirty patients underwent surgical treatment between 2009 and 2014. Kidney cancer was a primary disease in 30.3% of patients, multiple myeloma was a primary disease in 23.1% of cases, and the primary source of a tumor was not identified in cancer screening in 10.5% of cases. There were also isolated cases of melanoma, thymoma, metastases of tumors of the gastrointestinal tract, uterus, ovary, lung, prostate, pancreas, and the thyroid gland, which on the average amounted to 3.5% (1.8 to 7.14%). The quality of life of patients was studied using the EORTC QLQ C30 scale. The patients were surveyed prior to the surgery and then 1, 3, 6 and 12 months after surgical treatment during 1 year or until death. Preoperative and postoperative contrast-enhanced SCT and MRI examinations were used to control the extent of decompression of neural structures. RESULTS: On the basis of these findings, the authors identified the main factors affecting the quality of life of patients and formulated a range of treatment goals for patients with metastases in the spine. CONCLUSION: Surgical treatment has a positive effect on the quality of life of patients with metastases in the spine. However, it is not a key factor in the context of survival rate of these patients. Therefore, a decision on the possibility and necessity of surgical treatment should be taken in cooperation with the patient and oncologists of different specialties.

Rehabilitation Management of Hemicorporectomy.

This is a case report of a 55-year-old woman who was treated with a hemicorporectomy consequent to an invasive undifferentiated sacral chordoma. We describe the clinical course and rehabilitation process in an amputee outpatient clinic and report outcome measures such as the modified Functional Reach Test, the Amputee Mobility Predictor, the Functional Independence Measure, and the Short-Form Health Survey after 9 months of rehabilitation.

The effect of resistance training during radiotherapy on spinal bone metastases in cancer patients - a randomized trial.

PURPOSE: To compare the effects of resistance training versus passive physical therapy on bone density in the metastatic bone during radiation therapy (RT) as combined treatment in patients with spinal bone metastases. Secondly, to quantify pathological fractures after combined treatment. MATERIAL AND METHODS: In this randomized trial, 60 patients were allocated from September 2011 until March 2013 into one of the two groups: resistance training (group A) or passive physical therapy (group B) with thirty patients in each group during RT. Bone density in metastatic and non-metastatic vertebral bone was assessed at baseline, 3 and 6 months after RT. RESULTS: Bone density in all metastases increased significantly by 28.3% (IQR 11.4-139.0) and 80.3% (IQR 32.6-250.6) after 3 and 6 months in group A (both p < 0.01). The bone density in group A was significantly increased compared to control group after 3 and 6months (both p < 0.01, median 59.7; IQR 21.1-98.3 and median 62.9; IQR -9.7 to 161.7). The bone density data in group B showed no significant increase over the course of time (p = 0.289, median 5.5, IQR 0.0-62.2 and p = 0.057, median 52.1, IQR 0.0-162.7). 23.3% of the patients in group A and 30.0% of the patients in group B had pathological fractures, no fracture was assigned to intervention, and no difference between groups after 3 and 6 months was observed (p = 0.592 and p = 0.604). CONCLUSIONS: Our trial demonstrated that resistance training concomitant to RT can improve bone density in spinal bone metastases. This combined treatment is effective, practicable, and without side effects for patients. Importantly, the pathological fracture rate in the intervention group was not increased. The results offer a rationale for future large controlled investigations to confirm these findings. TRIAL REGISTRATION: Clinical trial identifier NCT01409720.

Large sacral osteoblastoma: a case report and review of multi-disciplinary management strategies.

INTRODUCTION: Osteoblastomas are uncommon primary benign bone tumors. The sacrum is an uncommon site of involvement. We present a case of a large, technically challenging sacral osteoblastoma in a pediatric patient that was managed with en-bloc resection and lumbo-sacral reconstruction showing long-term remission. CASE REPORT: A 15-year-old Hispanic male presented to our clinic in May 2006 with low back pain. Imaging revealed a large expansile and erosive mass at the S2 vertebral body. Definitive treatment of the lesion with en-bloc surgical resection was planned after a biopsy that confirmed osteoblastoma. The patient underwent pre-operative embolization and a same-day, two-stage resection of the tumor with lumbosacral instrumentation for pelvic reconstruction. The S1 nerve roots were sacrificed during en-bloc resection of the mass. Post-operatively, the patient developed an areflexic bladder without major motor or sensory impairment. Subsequently, insertion of an artificial urinary sphincter and a colostomy were performed. At the five-year follow up, the patient remains symptom free with no detectable recurrence. CONCLUSION: The sacrum is a known, but rare, location for an osteoblastoma. We present a technically challenging case of a pediatric patient with a large sacral osteoblastoma. We highlight the importance of a multidisciplinary approach to ensure a long-term, disease-free outcome.

Displasias vertebrales múltiples asociadas a Síndrome de Rokitansky: una causa poco frecuente de escoliosis congénita. A propósito de un caso / Multiple vertebral dysplasia associated with Rokitansky Syndrome: un uncommon cause of congenital scoliosis. Case report

Las displasias vertebrales son defectos del desarrollo que afectan principalmente a los cuerpos vertebrales, dando lugar a graves deformidades de la columna vertebral y de la caja torácica, en forma de escoliosis y cifoescoliosis congénitas. Pueden ser clasificadas en fallos de la formación, fallos de la segmentación o combinación de ambos. La localización y el tipo de defecto vertebral determinarán la gravedad de la curva patológica. Dichas anomalías pueden aparecer aisladas o asociadas a defectos neurales, viscerales y/o en las extremidades que deben ser descartados en el momento del diagnóstico, solicitando estudios genéticos y de imagen adicionales. El diagnostico precoz, así como el tratamiento rehabilitador con un exhaustivo seguimiento, son de vital importancia para prevenir la progresión de la escoliosis y las posibles complicaciones pulmonares. Presentamos un caso clínico muy poco frecuente, de múltiples anomalías vertebrales asociado a Síndrome de Rokitansky en una mujer que desarrolló escoliosis durante la pubertad (AU)

Vertebral dysplasia is a developmental defect, mainly of the vertebral bodies that cause severe spinal column and thoracic deformity that include congenital scoliosis and kyphoscoliosis. These vertebral anomalies can be classified as failure of formation, failure of segmentation, or a combination of both. The location and type of the vertebral defect determines the severity of the scoliosis. Is mandatory known that these abnormalities may be isolated or associated with concurrent neural, limb or visceral anomalies, which must be ruled out. Therefore additional imaging and genetical studies are necessary to provide evidence of these associated defects. Early diagnosis and rehabilitation treatment with exhaustive expectant watching are vital to prevent development of sever deformities and possible pulmonary complications. We report a representative case of multiple vertebral anomalies associated with Rokitansky Syndrome in a female who develops scoliosis during her puberty (AU)

[Open kyphoplasty for management of metastatic spine fracture]. / Traitement par kyphoplastie à foyer ouvert des métastases rachidiennes.

INTRODUCTION: Metastatic spine fractures are very frequent, often occurring in patients with severe medical conditions. Open kyphoplasty and vertebroplasty are part of the classic management of this of fracture. In certain conditions such as spinal cord compression caused by epidural metastatic cancer or collapse of the vertebral body implying a local kyphosis, surgery should allow decompression of the spinal cord and stabilisation of the spine in a simple act. The purpose of this study is to assess a surgical technique combining surgical decompression by laminectomy frequently associated with posterior transpedicular instrumentation and at the same time, an open kyphoplasty to stabilize the anterior part of the spine. MATERIAL AND METHODS: The same procedure was performed in 14 patients during an 18-month period. The average age of the patients was 54 years. All patients suffered severe pain before the surgical procedure (VSA mean: 7). Neurological deficiency was noted in 10 of the 14 patients with this spinal cord compression. Nineteen vertebrae were treated; a short posterior instrumentation was necessary in 11 patients. The average operative time was 90 minutes. Of the patients with neurological deficiency, the clinical status improved after surgery in all. The average VSA of this series 3 days after surgery was 2. The mean quantity of PMMA injected was 7 cc. Two PMMA leaks, one in the intervertebral disc and one forward, were identified on the postoperative CT scan. The average hospital stay was 7 days. CONCLUSION: This procedure enables surgical decompression, vertebral body consolidation and consequently spinal stabilization of the spine. We did not have any complications related to this procedure which, particularly for the elderly population, is an attractive alternative to major surgery such as vertebrectomy.

Barriers to rehabilitation of the neurosurgical spine cancer patient.

The treatment of metastatic spine tumors has evolved significantly over the past 20 years due largely to improvements in magnetic resonance imaging; decompressive surgical techniques, spinal instrumentation, and high-dose conformal radiation. These advances have improved our ability to provide meaningful palliation for patients who often have significant medical and cancer-related issues. Despite technical advances that have improved our ability to maintain neurologic function, stabilize the spine, and prevent local tumor recurrences, significant barriers to rehabilitation remain. This article reviews these primary barriers to rehabilitation of the cancer patient following spine surgery and emphasizes the importance of diagnostic accuracy and a comprehensive team approach to the treatment of pain and other disorders in this population.

Prognostic factors for survival in metastatic spinal cord compression: a retrospective study in a rehabilitation setting.

OBJECTIVE: Metastatic spinal cord compression (MSCC) occurs in 5-10% of all patients with cancer, and it is associated with short survival durations. Patients with MSCC may also have functional loss and require rehabilitation before discharge from the hospital. The purposes of this retrospective study were to identify clinical and social variables that had a significant impact on survival of patients with MSCC who underwent inpatient rehabilitation. DESIGN: A total of 60 consecutive patients with MSCC who were admitted to the inpatient rehabilitation unit at our tertiary care cancer center between 1996 and 1998 were included. Age, discharge destination, primary tumor site, metastasis, comorbidity, hemoglobin and albumin levels, treatment rendered for MSCC, opioids used, and psychological symptoms were examined as variables, and the Kaplan-Meier survival analysis was used. RESULTS: Our study showed that most of the variables we examined had no significant influence on survival time (median, 4.1 mo), with the exception of gastrointestinal cancer; patients with gastrointestinal cancer had a poorer prognosis (median survival durations, 0.6 mo; P < 0.0001). We also found a 1-mo gap between the time of diagnosis and the time of transfer to the rehabilitation unit. CONCLUSION: This study suggests that rehabilitation programs for patients with MSCC should be of short duration and that early referral (i.e., when the patient is diagnosed of MSCC) to the rehabilitation service should be encouraged.

[Clinical application of universal spine system in reconstruction of lumbar sacrum joint after resection of sacrum tumor].

OBJECTIVE: To investigate the operative indications and techniques of the universal spine system (USS) in reconstruction of the stability of the lumbar-sacrum joint after resection of sacrum tumor. METHODS: Nine patients were treated with USS after resection of sacrum tumor. Among them, there were 6 males and 3 females, aged from 34-60 years. The operation could be divided into four main procedures: 1. to resect sacrum tumor; 2. to insert the pedicle screw into the normal pedicle (L3 or L4 or L5) above the region of laminectomy; 3. to insert the lower screw into the iliac plate; 4. to put the rods, bone graft and links. RESULTS: There was no recurrence of sacrum tumor by MRI examination during 7-17 month follow-up. The pains of the lumbar-sacrum joint and the spinal nerve root were relieved obviously. The patients could stand and walked normally. There was no loose screw and no fracture of the screw and the rod. There was no appearance of the enlarged screw passage, the lessened pelvis and lowed L5 spine. CONCLUSION: Reconstruction of the lumbar-sacrum joint by the USS after resection of sacrum tumor is a practical operation clinically. It is characterized by the easy manipulation, few complication and stable fixation.

Lumbosacropelvic junction reconstruction resulting in early ambulation for patients with lumbosacral neoplasms or osteomyelitis.

Lumbosacropelvic junction instability may result from a variety of disease processes including primary and metastatic sacral tumors and degenerative disease. Regardless of the origin of the disease, restoring or maintaining spinal stability at this junction is essential for normal translation of axial forces from the lumbar spine and sacrum to the pelvis. Spinal stability is also critical for maintaining structural integrity, preventing neurological function deterioration, and alleviating resultant mechanical or axial pain. In this report, the authors describe one option for safe and effective spinal pelvic stabilization by using a transiliac rod and iliac bolt construct, which results in early postoperative ambulation, preserved neurological function, and reduced axial pain in selected patients.

Neural function preservation and early mobilization after resection of metastatic sacral tumors and lumbosacropelvic junction reconstruction. Report of three cases.

The management of tumors that metastasize to the sacrum remains controversial. Typically, resection of such tumors and reconstruction of the lumbopelvic junction requires sacrifice of neural elements resulting in neurological dysfunction and prolonged periods of bed rest. This severely affects the quality of life in patients in whom there is frequently a limited life expectancy. The authors describe three patients who underwent subtotal resection of metastatic sacral tumors. Postoperatively, good outcome was demonstrated in all patients. The authors present a technique for debulking and reconstruction that provides immediate spinopelvic junction stability and allows for early mobilization. Quality of life is significantly improved compared with that resulting from either medical treatment or traditional surgery.

[Patient with skeletal metastases. Mobile despite destroyed bones]. / Patient mit Skelettmetastasen. Mobil trotz zerstörter Knochen.

Bone metastases endanger both the mobility of the cancer patient and his ability to profit from medical/nursing care. Treatment aims to prevent fractures of the long bones and vertebrae and to avoid neurological defects caused by compression of the spinal cord. Treatment is indicated when the following criteria are met: for the long bones a defect measuring more than 2.5 cm in length or affecting more than 50% of the circumference; for the vertebrae destruction of more than 60%. Almost all patients require radiotherapy, with a minority also needing surgical treatment in the form of intralesional tumor resection, closure of the defect with bone cement, and the use of metal implants.

[Resection of spinal tumor and reconstruction of spinal stability].

OBJECTIVE: Both primary and metastatic tumor of spine can influence spinal stability, spinal cord and nerves. The principles of dealing spinal tumor are resection of tumor decompression on spinal cord and reconstruction of spinal stability. METHODS: Since Aug. 1993 to Oct. 1996, 15 cases with spinal tumor were treated, including 4 primary spinal tumor and 11 metastatic tumor. Tumor foci were mainly in thoracic and lumbar spine. Graded by Frankel classification of spinal injuries, there were 1 case of grade A, 1 of grade B, 3 of grade C, 5 of grade D and 5 of grade E. Tumors of upper lumbar spine and thoracic spine were resected through anterior approach. Posterior approach also was adopted once posterior column was affected. Tumors of lower lumbar spine were resected by two-staged operation: firstly, operation through posterior approach to reconstruct spinal stability: secondly, operation through anterior approach. After resection of tumor, the spines were fixed by Kaneda instrument, Steffee plate or Kirschner pins. To fuse the spine, bone grafting was used in benign tumor and bone cement used in malignant tumor. RESULTS: Except one patient died from arrest of bone marrow, the others were followed up for 3 to 20 months. Postoperatively, 11 patients could sit up on one foot with the help of body supporter, and 9 patients could walk in two weeks under careful monitoring. There was no exacerbation of symptom and failure of fixation. The function of spinal cord was improved: 1 case from grade B to grade E, 1 from A to C, 2 from C to E and 4 from D to E. CONCLUSION: The spine can be reconstructed for weight bearing early by internal fixation. The symptom can be relieved and the nervous function can be improved by resection of tumor and decompression.

Posterior decompression and stabilization for spinal metastases. Analysis of sixty-seven consecutive patients.

The neurological function, survival, and rehabilitation of sixty-seven consecutive patients who had been managed operatively for spinal metastases with epidural compression were assessed. The epidural compression was in the thoracic spine in forty-one patients and in the lumbar spine in twenty-six. According to the system of Frankel et al. for the assessment of neurological function, twenty-six patients had a major neurological deficit (grade B or C), thirty-two had a minor deficit (grade D), and nine had no deficit (grade E). None of the patients had an operation to treat a pathological vertebral fracture without epidural compression. The operative treatment included wide decompression through a posterior approach followed by stabilization without bone-grafting. A Cotrel-Dubousset device was used in thirty-two patients; an Olerud posterior fixator, in sixteen; an Isola device, in twelve; and another device, in seven. The most common complication was wound infection (eleven patients). There were no perioperative or immediate postoperative deaths (within fourteen days). The rate of survival was 51 per cent (thirty-four of sixty-seven) at six months and 22 per cent (fifteen of sixty-seven) at twelve months. Over-all, forty-four of the fifty-eight patients who had had a neurological deficit preoperatively had complete or partial neurological recovery within the first two weeks postoperatively. The nine patients who had not had a neurological deficit preoperatively retained normal neurological function postoperatively. Thirty-eight of the forty-four patients who were alive at three months and twenty-nine of the thirty-four who were alive at six months were still able to walk. Thirty-nine of the forty-nine patients who survived more than two months were able to return home for a median of seven months. Fourteen patients had a reoperation on the spine. Six of these patients had recurrent epidural compression at another level of the spine, and five had recurrent compression at the previously treated level. Three patients had a reoperation because of loosening of the implant. The results of this study suggest that neurological function can be maintained or improved by decompression and stabilization through a posterior approach as treatment for spinal metastases.

Postoperative ambulation of patients with intraspinal neurilemomas and meningiomas.

Factors affecting the postoperative ambulatory state of patients with intraspinal neurilemomas and meningiomas were evaluated in 92 patients who underwent surgery at the Chang Gung Memoriam Hospital. The patients' records were reviewed retrospectively and leg power grading was noted (Medical Research Council of Great Britain grading system, zero to five). Of the 89 patients with a preoperative leg power of 1 or better, 87 could walk with or without aids shortly after surgery. The remaining three patients, with a preoperative leg power of zero, were all wheelchair-bound postoperatively. The presence of sensory deficits and sphincter incontinence did not correlates with a poor postoperative ambulatory state, provided the preoperative leg power was above zero. The average period between the onset of the earliest symptoms and the establishment of the diagnosis was 68 weeks for patients with intraspinal neurilemomas and 71 weeks for those with meningiomas. Surgical for patients with neurilemomas were as good as those with meningiomas. Patients with multiple spinal neurilemomas did not fare any worse after surgery.

Prognostic factors of intraspinal neurilemmoma and meningioma with severe preoperative motor deficits.

A total of 20 cases of intraspinal benign tumors (13 neurilemmomas and seven meningiomas) with severe motor deficits operated on from 1978 to 1991 were reviewed. Motor deficits were graded according to the classification of Cooper and Ebstein. Grade IV represented slight movement of the lower extremities, but no ability to walk or stand; grade V was complete paralysis. There were 16 patients classified as grade IV and four classified as grade V. All patients underwent total excision of the tumor and postoperative physical therapy. After various periods of follow-up, 13 patients could walk independently, five could walk with assistance, one could stand, and one was still restricted to a wheelchair. For the 13 patients who could walk independently, 11 were able to stand within one month after surgery. In contrast, of the seven patients who could not walk independently, only two managed to stand within one month of surgery. Statistically, age, duration of paraplegia and tumor location all had a significant influence on the recovery of motor function. Being able to stand within one month of surgery was predictive of a good recovery.