Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem.

PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Carbon Fiber-Reinforced PolyEtherEtherKetone (CFR-PEEK) Instrumentation in Degenerative Disease of Lumbar Spine: A Pilot Study.

CFR-PEEK is gaining popularity in spinal oncological applications due to its reduction of imaging artifacts and radiation scattering compared with titanium, which allows for better oncological follow-up and efficacy of radiotherapy. We evaluated the use of these materials for the treatment of lumbar degenerative diseases (DDs) and considered the biomechanical potential of the carbon fiber in relation to its modulus of elasticity being similar to that of bone. Twenty-eight patients with DDs were treated using CRF-PEEK instrumentation. The clinical and radiographic outcomes were collected at a 12-month FU. Spinal fusion was evaluated in the CT scans using Brantigan scores, while the clinical outcomes were evaluated using VAS, SF-12, and EQ-5D scores. Out of the patients evaluated at the 12-month FU, 89% showed complete or almost certain fusion (Brantigan score D and E) and presented a significant improvement in all clinical parameters; the patients also presented VAS scores ranging from 6.81 ± 2.01 to 0.85 ± 1.32, EQ-5D scores ranging from 53.4 ± 19.3 to 85.0 ± 13.7, SF-12 physical component scores (PCSs) ranging from 29.35 ± 7.04 to 51.36 ± 9.75, and SF-12 mental component scores (MCSs) ranging from 39.89 ± 11.70 to 53.24 ± 9.24. No mechanical complications related to the implant were detected, and the patients reported a better tolerance of the instrumentation compared with titanium. No other series of patients affected by DD that was stabilized using carbon fiber implants have been reported in the literature. The results of this pilot study indicate the efficacy and safety of these implants and support their use also for spinal degenerative diseases.

Indications and Limits of Surgery for Spinal Metastases Derived from Lung Cancer: A Single-Center Experience.

Lung cancer is the second most frequently diagnosed cancer in the world, and surgery is an integral part of the treatment for spinal metastases. The aims of this retrospective study were to assess the overall survival of surgically treated patients affected by lung cancer spinal metastases and identify any factors related to a better survival rate. We recruited 56 consecutive patients (34 male and 22 female) surgically treated for metastatic lung cancer in the spine from 2009 to 2019. Surgical indications were based on a previously published and validated flow chart following a multidisciplinary evaluation. We assessed the localization of vertebral metastases, the presence of other bone or visceral metastases, neurological status according to the Frankel score, ambulatory autonomy, and general status, measured with the Karnofsky performance scale. The expected prognosis was retrospectively assessed according to the revised Tokuhashi score. The median survival was 8.1 months, with over a third of patients surviving more than 1 year. We observed a global improvement in all clinical parameters after surgical treatment. The Tokuhashi predictive score did not correlate with survival after surgery. The results of this study suggest that the surgical treatment of symptomatic spinal metastases from lung cancer can improve quality of life, even in patients with a shorter life expectancy, by controlling pain and improving autonomy.

Clinical and Pathological Profiles of Vertebral Bone Metastases from Endometrial Cancers: Evidence from a Twenty-Year Case Series.

Patients with endometrial cancer (EC) frequently have metastases to lungs, extra-pelvic nodes, and liver. Although an uncommon occurrence, cases of EC metastasis to bone, prevalently in vertebral bone, have also been reported. The objective of this study was to analyze clinical and pathological profiles of patients with EC metastatic to vertebral bone. We carried out a retrospective case series on surgically treated patients for this pathology. From 2001 to 2021, out of 775 patients with bone metastasis, 1.6% had bone metastasis from EC. The median time between the diagnosis of primary tumor and that of bone metastases was 31.5 months. Solitary bone lesion was present in 7 patients and lumbar vertebrae were the segments most affected. Pathological fractures in 46.2% of patients and spinal pain in all were present. In terms of location, 46.2% of bone metastases resided within the anterior section of the vertebra, while the remaining presented an extension within the anterior and posterior sections, with 46.1% of cases showing an extradural extra-osseous extension and paraspinous envelope. Median survival after diagnosis of bone metastasis was 11.5 months. Vertebral bone metastasis in EC is a rare phenomenon, with severe prognosis. An in-depth understanding of this topic may guide future management and treatment decisions, thus improving life expectancy and quality.

Clear Cell Renal Cell Carcinoma Spinal Metastases: Which Factors Matter to the Overall Survival? A 10-Year Experience of a High-Volume Tumor Spine Center.

Clear cell renal cell carcinoma (ccRCC) usually spreads in the spinal region causing instability or spinal cord compression leading to neurological deficits. Therefore, surgical treatment is required for improving the outcome of patients. The aim of this study is to identify which prognostic factors could affect overall survival in patients affected by ccRCC. Methods: Retrospective cohort study of patients with ccRCC spinal metastases, surgically treated from November 2009 to April 2019. Demographic and clinical data were collected. The Kaplan−Meier method was used to estimate overall survival, and the log-rank test was used to evaluate differences in survival among potentially prognostic factors. Results: A total of 69 patients were surgically treated and followed up for a median period of 65 months. The average age at the time of surgery was 62.6 years old. The median overall survival (OS) was 34.7 months (95% CI 20.8−51.9) and 5-year OS was 31.2% (95% CI 19.2−44.1). A high Tokuhashi score (p = 0.0217), the presence of visceral metastases (p < 0.001), other bone metastases (p = 0.02012) and the kind of surgical treatment (p = 0.0395) are the main prognostic factors that influence the OS. Moreover, 3-year progression-free survival (PFS) was analyzed: the median PFS was 53.1 months and the % 3-year PFS was 62.9% (45.2−76.3). In the multivariate analysis, only pre-operative radiation therapy had a significant impact on 3-year PFS (95% CI 0.929−12.994, p = 0.0643). Conclusion: The results of this study suggest that the absence of visceral metastases and an aggressive surgery as en-bloc, when feasible, could prolong the survival rate and improve quality of life for patients.

Custom-Made 3D-Printed Implants for Anterior Column Reconstruction in the Upper Cervical Spine after Intralesional Extracapsular Excision-Report of 2 Cases and Literature Review.

The use of three-dimensional (3D)-printed custom-made implants is spreading in the orthopedics field for the reconstruction of bone losses or for joint replacement, thanks to their unparalleled versatility. In particular, this novel technology opens new perspectives to formulate custom-made fixation strategies for the upper cervical region, sacrum and pelvis, where reconstruction is challenging. We report and analyze the literature concerning upper cervical reconstruction with 3D-printed personalized implants after tumor surgery, and discuss two cases of patients where this technology was used to reconstruct the anterior column after extracapsular debulking of C2 recurrent chordoma at our institution.

Complications and Risk Factors in En Bloc Resection of Spinal Tumors: A Retrospective Analysis on 298 Patients Treated in a Single Institution.

En bloc resection consists in the surgical removal of a vertebral tumor in a single piece with a sufficient margin, to improve survival and reduce recurrence rate. This procedure is technically demanding and correlates with a high complication rate. The purpose of this study is to investigate the risk factors for complications in en bloc resection and evaluate if benefits overcome the risks in term of overall survival. We retrospectively analyzed prospectively collected data of patients treated with en bloc resection between 1980 and 2021. Complications were classified according to SAVES-V2. Overall Survival was estimated using Kaplan-Meier method. A total of 149 patients out of 298 (50%) suffered from at least one complication. Moreover, 220 adverse events were collected (67 intraoperative, 82 early post-operative, 71 late post-operative), 54% of these were classified as grade 3 (in a severity scale from 1 to 6). Ten years overall survival was 67% (95% CI 59-74). The occurrence of relapses was associated to an increased risk of mortality with OR 3.4 (95% CI 2.1-5.5), while complications did not affect the overall survival. Despite a high complication rate, en bloc resection allows for a better control of disease and should be performed in selected patients by specialized surgeons.

Autologous mesenchymal stem cells in the treatment of spinal aneurysmal bone cyst.

PURPOSE: We retrospectively analyzed a cohort of patients treated at our Centre with bone marrow concentrated (BMC) injection for aneurysmal bone cyst (ABC) of the spine, in order to propose this treatment as a valid alternative for the management of ABCs. METHODS: Fourteen patients (6 male, 8 female) were treated between June 2014 to December 2019 with BMC injection for ABC of the spine. The mean age was 15.5 years. The mean follow up was 37.4 months (range 12-60 months). The dimension of the cyst and the degree of ossification were measured by Computed Tomography (CT) scans before the treatment and during follow-up visits. RESULTS: Six patients received a single dose of BMC, five patients received two doses and in three patients three doses of BMC were administered. The mean ossification of the cyst (expressed in Hounsfield units) increased statistically from 43.48 ± 2.36 HU to 161.71 ± 23.48 HU during follow-up time and the ossification was associated to an improvement of the clinical outcomes. The mean ossification over time was significantly higher in patients treated with a single injection compared to patients treated with multiple injections. No significant difference in ossification was found between cervical and non-cervical localization of the cyst. Moreover, the initial size of the cyst was not statistically associated with the degree of ossification during follow-up CONCLUSIONS: Results of this paper reinforce our previous evidence on the use of BMC as a valid alternative for spinal ABC management when SAE treatment is contraindicated or ineffective.

Postoperative Survival and Clinical Outcomes for Uterine Leiomyosarcoma Spinal Bone Metastasis: A Case Series and Systematic Literature Review.

Spinal bone metastases from uterine leiomyosarcoma (LMS) are relatively uncommon and few data are present in the literature. In this study, cases of nine consecutive patients who underwent spinal surgery for metastatic uterine LMS between 2012 and 2022 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by changes in Frankel grade classification during follow-up. A systematic review of the literature was also performed to evaluate operative and postoperative factors and outcomes for patients with the same gynecological metastases to the spine. For our cases, the mean time between primary tumors to bone metastases diagnosis was 5.2 years, and the thoracic vertebrae were the most affected segment. Overall, median survival after diagnosis of metastatic spine lesions was 46 months. For the systematic review, the mean time between primary tumors to bone metastases was 4.9 years, with the lumbar spine as the most involved site of metastasis. Overall, median survival after diagnosis was 102 months. Once a spinal bone lesion from LMS is identified, surgical treatment can be beneficial and successful in alleviating symptoms. Further efforts will be crucial to identify prognostic markers as well as therapeutic targets to improve survival in these patients.

Surgery Versus Radiofrequency Ablation in the Management of Spinal Osteoid Osteomas: A Spine Oncology Referral Center Comparison Analysis of 138 Cases.

BACKGROUND: Osteoid osteomas (OOs) are benign bone forming tumors that, usually, occur in the extremities, with about 10% of them arising in the spine more commonly in the posterior elements. The aim of this study is to evaluate the long-term results of patients suffering from spinal OO treated with surgery and radiofrequency ablation. METHODS: This was a retrospective comparison analysis of data prospectively collected from 2 cohorts of consecutive patients diagnosed with OO of the spine treated at the same Institute from November 2002 to February 2019. The first cohort included patients submitted to an intralesional extracapsular excision of the lesion (surgery group); the second cohort included patients submitted to radiofrequency ablation (RFA group). RESULTS: The surgery group showed a local recurrence rate of 1.7% versus a recurrence rate of 12.5% in the RFA group with a statistically significant difference in the disease-free survival at longest follow-up (P = 0.012). No statistically significant differences were observed in local recurrence rate stratified for level and site of lesion. No complications were observed in both groups at the time of first procedure. CONCLUSIONS: Surgery and RFA are both safe and effective interventional procedures for the management of spinal OO, although RFA is associated with a greater recurrence rate. Treatment should be tailored according to the relationship of lesions with neural structures and to advantages and disadvantages of each technique.

Denosumab in the treatment of giant cell tumor of the spine. Preliminary report, review of the literature and protocol proposal.

BACKGROUND: The interest on the role of Denosumab in the treatment strategy of giant cell tumor of the spine is growing. En bloc resection is considered the Enneking appropriate treatment, but morbidity and functional loss are sometimes unacceptable. Denosumab could play a role as a stand-alone treatment, but also as preoperative treatment or as postoperative after intralesional surgery. MATERIALS AND METHODS: A cohort of 10 out of 12 cases of spinal GCT consecutively treated with Denosumab are analyzed and discussed compared to the cases reported in the literature. A staging of the radiological effect of the treatment is proposed. RESULTS: The stand-alone and postoperative treatments are still running (12 to 88 months). One therapy was stopped after 15 months, once a satisfactory local effect was achieved, but the treatment had to be restarted 2 months later due to the recurrence of the erosive images. The new treatment was successful. At 1-year follow-up after the gross total excision followed by postoperative Denosumab treatment, no evidence of local recurrence was found. The preoperative treatment duration ranged from 3 to 24 months. No local recurrence followed the en bloc resections. CONCLUSIONS: Denosumab alone is effective in relieving pain, increasing the ossification and sometimes reducing the tumor volume. It can be considered an excellent solution in spine GCTs whose surgical treatment cannot be Enneking appropriate or is associated with unacceptable morbidity or loss of functions. It is still impossible to state when to safely stop the treatment. Denosumab also plays a role as preoperative protocol. These slides can be retrieved under Electronic Supplementary Material.

Function Preservation or Oncological Appropriateness in Spinal Bone Tumors?: A Case Series of Segmental Resection of the Spinal Canal Content (Spinal Amputation).

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To evaluate (1) if the segmental resection of the content of the spinal canal could provide an Enneking appropriate tumor-free margin for local control of primary bone tumors surrounding and invading the canal and (2) the safety profile of the segmental resection of the neurostructures. SUMMARY OF BACKGROUND DATA: Treatment outcomes of primary malignant and benign aggressive bone tumors of the spine have been dramatically changed by the application of the musculoskeletal oncologic principles described by Enneking. However, the efficacy of spinal oncology surgery might be limited by unique features of spinal anatomy. METHODS: Database search was conducted with the following inclusion criteria: en bloc resection, segmental inclusion of the spinal canal content in the surgical specimen, histologically proven diagnosis, minimum follow-up of 2 years. Exclusion criteria were piecemeal excision of the tumor (debulking) and diagnosis other than primary bone tumors (metastasis, or local extension of extraosseous tumors). RESULTS: A consecutive cohort of eight patients (three men, five women) was available for review. Two patients died within 3 months from the surgery for systemic disease progression or sequelae of the surgery. En bloc resection with segmental spinal canal content inclusion was able to achieve local control of the disease in four out of remaining six cases (66.7%) at an average follow-up of 68.7 months (range 12-174 mo). Three patients in whom local control was achieved are free from disease at an average follow-up of 98.7 months (range 38-174), and one died for systemic disease progression (after 38 mo). Seven out of 8 patients (87.5%) experienced overall 16 complications. CONCLUSION: En bloc resection including the spinal canal content (spinal amputation) to achieve a tumor-free margin might be considered to perform an Enneking appropriate treatment for motivated patients. LEVEL OF EVIDENCE: 4.

Can Osteoblastoma Evolve to Malignancy? A Challenge in the Decision-Making Process of a Benign Spine Tumor.

BACKGROUND: Osteoblastoma is a rare benign aggressive tumor, with one third occurring in the spine. Conversion of osteoblastoma to osteosarcoma is uncommon, and histologically proven conversion has been rarely reported. CASE DESCRIPTION: Cases of 2 patients with rare occurrences of spinal osteoblastomas recurring and transforming into osteosarcomas are presented. Initial presentation, treatment, imaging, and histology findings are described. The outcomes of the patients following surgical intervention for histologically diagnosed osteoblastoma with subsequent transformation to osteosarcoma and relative management are described. A literature review of osteoblastoma converting to osteosarcoma also is provided. CONCLUSIONS: The rare occurrence of osteoblastoma converting to osteosarcoma imparts several lessons, including performing Enneking appropriate surgery for benign aggressive tumors (Enneking stage 3) and always performing a biopsy, particularly at the time of recurrence if imaging is not pathognomonic for a benign primary spine tumor.

Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

PURPOSE: To investigate whether the World Health Organization Safety Surgical Checklist (SSC) is an effective tool to reduce complications in spinal surgery. METHODS: We retrospectively evaluated the clinical and radiological charts prospectively collected from patients who underwent a spinal surgery procedure from January 2010 to December 2012. The aim of this study was to compare the incidence of complications between two periods, from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist's effectiveness. RESULTS: The sample size was 917 patients with an average of 30-month follow-up. The mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). In total, 159 complications were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction in the overall incidence of complications following the introduction of the SSC: In 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). CONCLUSIONS: The SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the preoperative and postoperative phases in order to further reduce the incidence of complications. These slides can be retrieved under Electronic Supplementary Material.

Correction to: Primary vascular bone tumors in the spine: a challenge for pathologists and spine oncology surgeons.

Unfortunately, the affiliation for the following authors was incorrectly published in the original publication.

Paraganglioma of the spine: A twenty-years clinical experience of a high volume tumor center.

Paragangliomas (PGs) are rare tumours with a reported estimated annual incidence of up to 3 per million. Spinal involvement may possible with spinal metastasis and primary extradural localizations. The aim of this paper is to evaluate clinical outcomes of surgical treatment of a rare disease that can involve the spine and that should be considered in the differential diagnosis of spinal injuries. This is a retrospective observational study of the spinal paragangliomas treated at our institute. Five patients have been enrolled: three with metastatic PG and two with extradural PG. Metastatic PGs were treated with intralesional excision plus adjuvant therapies instead, extradural PGs with intralesional excision without adjuvant therapies. Among patients affected by metastastic paraganglioma two patients were Alive with disease (AWD) at the latest follow and one patient died for the spreading of disease at 240 months after surgery. Two patients with extradural paraganglioma of thoracic spine were AWD at the latest follow-up without pain and neurological deficits. Surgical management of spinal localizations can represent a challenge. Surgery has a main role in both diseases where intralesional excision plus adjuvant therapies seems to be able to achieve the local control and a satisfying prognosis in case of undisseminated tumour.

Primary vascular bone tumors in the spine: a challenge for pathologists and spine oncology surgeons.

PURPOSE: Primary vascular bone tumors of the spine represent a challenge for oncology surgeons, due to the need of planning a surgical strategy appropriate to the tumor behavior. But these tumors represent a challenge also for pathologists, as immunohistochemical and molecular analyses have recently refined the terminology. METHODS: A cohort of 81 cases was retrospectively reviewed, targeting the evolution of diagnoses and the treatment-related outcome. Sixty-six cases (including one case originally diagnosed as chordoma) were diagnosed before 2011, and 15 were diagnosed and treated in the period 2011-2017. Fully documented outcome studies are available for 46 patients whose immunohistochemical and molecular analyses were available. The follow-up ranges from 6 months of the early patient death to 300 months of the longest disease-free survival. RESULTS: The outcome was related not only to the treatment performed, but also to the evolution of diagnoses. The term Hemangioendothelioma that defined a benign aggressive (Enneking stage 3) tumor is now obsolete and replaced by the diagnosis of Epithelioid Hemangioma for benign aggressive tumor and Epithelioid Hemangioendothelioma for low-grade malignant tumor. En bloc resection was appropriate for local control, but 2 out of 7 cases of epithelioid Hemangioendotheliomas died due to the spread of the disease None of the Hemangiomas recurred after intralesional excision with or without radiotherapy, or after vertebroplasty. Both cases of Angiosarcoma had a fast and lethal evolution. CONCLUSIONS: Surgeons must be aware of the evolution of terminology to decide the most appropriate treatment options. These slides can be retrieved from Electronic Supplementary Material.

Biomimetic 3D-printed custom-made prosthesis for anterior column reconstruction in the thoracolumbar spine: a tailored option following en bloc resection for spinal tumors : Preliminary results on a case-series of 13 patients.

PURPOSE: Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine. METHODS: Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded. RESULTS: Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone-implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2-16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis. CONCLUSION: Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material.

Metastatic epidural spinal cord compression: does timing of surgery influence the chance of neurological recovery? An observational case-control study.

PURPOSE: Metastatic epidural spinal cord compression (MESCC) is radiologically defined as an epidural metastatic lesion causing the displacement of the spinal cord from its normal position in the vertebral canal. The purpose of this paper is the evaluation of the influence of timing of surgery on the chance of neurological recovery. METHODS: This is a retrospective observational case-control study performed on patients with MESCC from solid tumors surgically treated at our institute from January 2010 to December 2016. Patients included were divided in two groups depending on surgery that was performed within or after 24 h the admission to the hospital. Neurological status was assessed with American Spine Injury Association (ASIA) Impairment Scale. RESULTS: No statistically significant difference was observed in the variation of ASIA if surgery is performed within or after 24 h from the admission to the hospital. A statistically significant difference was observed after surgery in each group in the improvement of neurological status. A statistically significant difference was reported in the early post-operative complications in patients surgically treated within 24 h. CONCLUSION: MESCC management is challenge for spine surgeons and may represent an oncologic emergency and if not promptly diagnosed can lead to a permanent neurological damage. According to this study, there is no difference in the chance of neurological recovery if surgery is performed within or after 24 h the admission to hospital, but there is a greater rate of early post-operative complications when surgery is performed within 24 h from the admission to the hospital.