Complications associated with cervical vertebral body replacement with expandable titanium cages.

Our aim was to analyze complications and risk factors for cervical vertebral body replacement (VBR) with expandable titanium cages (ETC). Fifty patients; 22 women and 28 men, mean age 61years, undergoing cervical VBR from 2010 to 2015 were analyzed. Complications were stratified by hardware-association (HA). Univariate and multivariate logistic regression was used to identify independent risk factors. Single, two and three level corpectomies were performed in 32, 15 and 3 patients respectively. A circumferential approach was necessary in 16 cases. At mean follow-up (7.3 months) 66% of patients had recovered. Radiological data showed a significant distraction (2.60mm, p<0.0001) and lordosis (5°, p=0.001). Twenty-three patients experienced 42 complications; 18 HA, 24 non-HA and 24% needed revision surgery. The number of corpectomy levels and surgical approach significantly correlated with the risk of complications (p=0.001), especially non-HA complications (p=0.002). On multivariate analysis, only the number of corpectomy levels (p<0.02, odds ratio 5.48, 95% CI 1.31-22.91) was a significant predictor of complications. We conclude that ETC are efficacious devices for cervical spine VBR, however, when used for more than 1 level, the corpectomy complication rate significantly increases.

Radiological and clinical results of patients after ACDF with and without preoperative software-assisted cage selection.

OBJECTIVE: Comparison of software facilitated preoperatively-selected cages versus standard intraoperatively-selected cages, assessing radiological and clinical outcomes of patients after single level cervical discectomy and fusion (ACDF). METHODS: Cages of study group patients were preoperatively chosen via software-aided dimensioning. Controls obtained cages determined by intraoperative trail implants. Primary endpoints were segmental height (SH), regional angulation (RA) and global cervical angulation (GCA) measured on plain radiographs before, immediately and 12 months after surgery. Neck pain on the visual analogue scale, the neck disability index, and patient satisfaction index recorded at 12 months follow up (FU) were the secondary endpoints. RESULTS: Each group comprised of 20 patients and both depicted similar demographics and operated segmental levels. Mean postoperative SH was significantly increased in both study and control groups, p<0.001* and p=0.006* respectively. Immediate postoperative gain of lordosis was only significant for the study group p<0.001*. At 12 months FU, SH and RA decreased significantly in both groups. GCA and all secondary endpoints were similar for various measured time points. The two groups did not show any significant difference for all investigated parameters. CONCLUSION: The radiographical and clinical outcomes of patients receiving cages preoperatively selected by software-assistance are similar to that of patients obtaining conventionally chosen cages. However the former allows for better regional gain/restoration of lordosis.

Lumbar juxta-facet joint cysts in association with facet joint orientation, -tropism and -arthritis: A case-control study.

OBJECTIVE: To assess the association between juxta-facet-joint cysts (JFC) occurrence at the lumbar spine and Facet Joint (FJ) orientation, -tropism and -arthritis. METHODS: Study group, 36 consecutive patients with JFC and the same number of controls, with degenerative diseases without JFC were match paired for demographics and spine segment. Parameter assessment was by T2-weighted axial MRI scans. JFC diagnosis was confirmed histopathologically. Group comparison was by Student's t-test for continuous variables and X(2) for categorical variables. RESULTS: Nineteen female and 17 male patients, aged between 45 and 85 years (mean 67.19 ± 10.3 years) had a mean JFC size of 9.26 ± 4.8mm occurring most frequently in the segment L4-L5 (75% n=25) and on the left side (61%). Mean FJ orientation of the study group was significantly more coronal compared to controls (left side 42° vs 36°, p<0.02*, 95% confidence interval: 0.9-11.5 and right side 43° vs 37°, p<0.02*, 95% confidence interval: 0.6-10.6 respectively). However, individual intersegmental analysis for study group patients showed the JFC bearing side to be significantly more sagittally oriented 40° ± 11.2° compared to 45° ± 13.2° for the side without FJC (p<0.03*, 95% confidence interval: 8.1-1.7). 50% of the study group showed FJ asymmetry compared to 30% in controls, with a trend for FJ tropism (p<0.07). Severe (grade 3) FJ arthritis was significantly more predominant in the study group 23/33 (p<0.001*) as compared to controls. CONCLUSIONS: Compared to a control group, JFC occurrence is associated with significant higher rates of arthritis and coronally orientated FJ. At intersegment comparison within the same patient cysts located in more sagittally orientated FJ and the asymmetric segments show a trend for FJ tropism.

Repeat-surgery at Glioblastoma recurrence, when and why to operate?

OBJECTIVE: Glioblastoma (GB) recurrence is inevitable; guidelines for treatment at disease recurrence are deficient. Clinicians are faced with deciding whom to choose for repeat-surgery. This study analyzes recurrence therapy modalities, investigates characteristics of patients operated on at recurrence and evaluates outcome benefit. METHODS: Consecutive adult patients operated on for de novo GB at a single institution from 2006 to 2011 were reviewed. Clinical, radiographic and molecular data of 141 patients diagnosed of recurrent disease were assessed. Reasons for recurrence therapy and therapy modalities were reviewed. Univariate analysis was used to analyze differences in parameters of patients operated on at recurrence and those not. Impact of re-operation on survival was evaluated by the Kaplan-Meier method and Log-rank test. RESULTS: 53 (38%) patients were selected for repeat surgery upon recurrent disease, this was followed by either chemotherapy (CT) (40%), radiotherapy (8%) or both (49%). 57 (40%) patients received CT alone, which was the most frequent mono-second-line therapy opted for. Most frequent indications for repeat-surgery were maximum possible tumor resection mass reduction and symptom relief (62% and 21%, respectively). Univariate analysis of re-operated vs. not operated patients, showed significant differences for age (p=0.0001*) and Karnofsky Performance status (KPS) >70 at both primary and repeat tumor resection (p=0.013* and 0.0001*, respectively). The operated group had a significantly lower Charlson-comorbidity-index≤3 (p=0.004*) and larger tumor size (p=0.0001*). Complication risk at recurrence was not significantly different between groups (p=0.069). However, patients chosen for repeat surgery had significantly less complications at index surgery (p=0.006*). Median time from recurrence to death was 11 months (range, 1-33 months) for operated patients as opposed to 5 months (range, 0-22 months) for not operated patients. The former survived significantly longer; 19 months compared to 13 months for those not operated upon (p=0.002*). CONCLUSIONS: Our study depicts that patients eligible for repeat-surgery at GB recurrence are characterized by a KPS>70% before primary and repeat-surgery, Charlson-comorbidity-index≤3, large tumor size and young age. These well-selected patients survive significantly longer after repeat-surgery without being at a higher complication risk in comparison to patients not operated upon.

Risk factors for glioblastoma therapy associated complications.

OBJECTIVE: Thromboembolic events, seizures, neurologic symptoms and adverse effects from corticosteroids and chemotherapies are frequent clinical complications seen in Glioblastoma (GB) patients. The exact impact these have on dismal patient outcome has not been fully elucidated. We aimed at assessing treatment associated complications, evaluating the impact on survival and defining risk factors. METHODS: Two hundred and thirty three consecutive adult patients operated on for newly diagnosed GB at a single tertiary institution over a 5-year-period (2006-2011) were assessed. Demographic parameters (age, gender, comorbidity status quantified by the Charlson-comorbidity-index (CCI), functional status computed by the Karnofsky Performance Scale (KPS), tumor characteristics (size, location, IDH-1 mutation and MGMT-Promotor-methylation-status) and treatment parameters (volumetrically quantified extent of resection and adjuvant therapy) were retrospectively reviewed. Complications assessed were recorded as neurological (N), surgical (S) and medical (M). Independent risk factor analysis was performed by the univariate and multivariate logistic regression method. Survival analysis was plotted by the Kaplan-Meier-method, influence of complication occurrence was evaluated by the log-rank test. RESULTS: One hundred and fifty nine (68.2%) patients had a total of 281 complications (90 N, 174 M and 17 S). Univariate analysis identified age (P=0.003), KPS<70 (P=0.002), CCI>3 (P=0.03), eloquent tumor location (P=0.001) and therapy other than the standard radio-chemotherapy with temozolomide therapy (P=0.034) as risk factors for complications. Multivariate analysis extracted the eloquent tumor location (P=0.007, odds ratio 1.94) as a significant predictor for complications. Having a complication significantly decreased patient survival (P=0.015). CONCLUSIONS: Complications significantly decrease GB patient survival. Age, poor functional status, other than standard adjuvant therapy and eloquent tumor location proved as significant risk factors for encountering a therapy associated complication. Not extensive surgery or tumor size but surgery at eloquent locations impacts complication occurrence the strongest with a 2 fold increased complication occurrence risk.