Faculty Bibliography
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210
Role of Posterior Carbon Fiber Implants in Spine Tumor Surgery
STUDY DESIGN/METHODS:Narrative Review. OBJECTIVE:The management of spinal tumors requires a multi-disciplinary approach including surgery, radiation, and systemic therapy. Surgical approaches typically require posterior segmental instrumentation to maintain long-term spinal stability. Carbon fiber reinforced pedicle screws (CFRP) are increasingly used in the oncologic setting due to reductions in both imaging artifacts and radiotherapy perturbations compared to titanium implants. We performed a review of the literature and highlight advantages and future areas of study for CFRP. METHODS:We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 10 articles including 573 patients. Across all studies we reviewed patient demographics, tumor types treated, hardware-related features, complication rates, recurrence, survival, and follow-up. RESULTS:Across 10 studies, a total of 1371 screws placed. Surgical and non-surgical complications were reported in 18.3% of patients. Disease progression at the surgical site was detected in 7.3% of patients. There was no significant difference in clinical or hardware complications between CFRP or titanium implants. The most frequent complication attributable to implanted CFRP hardware included screw breakage in 2.4% and loosening in 1.7% of patients, respectively. CONCLUSION/CONCLUSIONS:CFRP provide a unique tool in the setting of spinal oncology. With a safety profile comparable to titanium, we review the documented advantages of CFRP posterior implants compared to titanium, while also addressing their current limitations. Additionally, we highlight several areas of future research to identify the optimal patients who will achieve the greatest benefit of CFRP.
PMCID:11726513
PMID: 39801115
ISSN: 2192-5682
CID: 5775902
Liquid Biopsy for Spinal Tumors: On the Frontiers of Clinical Application
STUDY DESIGN/METHODS:Narrative review. OBJECTIVES/OBJECTIVE:This article aims to provide a narrative review of the current state of research for liquid biopsy in spinal tumors and to discuss the potential application of liquid biopsy in the clinical management of patients with spinal tumors. METHODS:A comprehensive review of the literature was performed using PubMed, Google Scholar, Medline, Embase and Cochrane databases, and the review was limited to articles of English language. All the relevant articles which were identified to be related to liquid biomarker study in spinal tumors, were studied in full text. RESULTS:Liquid biopsy has revolutionized the field of precision medicine by guiding personalized clinical management of cancer patients based on the liquid biomarker status. In recent years, more research has been done to investigate its potential utilization in patients with tumors from the spine. Herein, we review the liquid biomarkers that have been proposed in different spine malignancies including chordoma, chondrosarcoma, Ewing sarcoma, osteosarcoma, astrocytoma and ependymoma. We also discuss the wide window of opportunity to utilize these liquid biomarkers in diagnosis, treatment response, monitoring, and detection of minimal residual disease in patients with spinal tumors. CONCLUSIONS:Liquid biomarkers, especially blood-derived circulating tumor DNA, has a promising clinical utility as they are disease-specific, minimally invasive, and the procedure is repeatable. Prospective studies with larger populations are needed to fully establish its use in the setting of spinal tumors.
PMCID:11726521
PMID: 39801114
ISSN: 2192-5682
CID: 5775882
Advanced Radiotherapy Technologies in Spine Tumors: What the Surgeon Needs to Know
STUDY DESIGN/METHODS:Narrative review of existing literature. OBJECTIVES/OBJECTIVE:Significant technological advancements in radiotherapy planning and delivery have enabled new radiotherapy techniques for the management of spine tumors. The objective of this study was to provide a comprehensive summary of these treatment techniques for practicing spine surgeons. METHODS:A narrative review of the existing literature on stereotactic body radiation therapy (SBRT) and particle beam therapy (PBT) for the treatment of spine tumors was performed. The characteristics, implementation and evidence supporting these strategies in the management of primary spinal neoplasms were summarized. RESULTS:The clinical effectiveness of SBRT for the control and symptom palliation of metastatic spinal tumors are well demonstrated in multiple clinical trials. Risks such as fracture, radiculopathy and plexopathy exist after spine SBRT, necessitating an individualized approach in a well experienced multidisciplinary setting. SBRT should be considered a key component of a well-rounded treatment plan for metastatic spine tumors in combination with surgery, vertebral augmentation, and drug therapy, where indicated, to achieve optimal patient outcomes. Additionally, PBT and SBRT are also leading to promising results for primary spine tumors, though comparative effectiveness studies and prospective clinical trials are required to establish these modalities more formally as alternatives to conventionally fractionated photon radiotherapy. CONCLUSIONS:SBRT and PBT are emerging as effective and well tolerated treatment options for primary and metastatic spine tumors. Additional investigation is needed to personalize these treatment options and further strengthen these approaches as key components in a multidisciplinary approach to the management of spinal neoplasms.
PMCID:11726527
PMID: 39801121
ISSN: 2192-5682
CID: 5776002
Prevention and Management of Posterior Wound Complications Following Oncologic Spine Surgery: Narrative Review of Available Evidence and Proposed Clinical Decision-Making Algorithm
STUDY DESIGN/METHODS:Narrative Review. OBJECTIVE:Contextualized by a narrative review of recent literature, we propose a wound complication prevention and management algorithm for spinal oncology patients. We highlight available strategies and motivate future research to identify optimal and individualized wound management for this population. METHODS:We conducted a search of recent studies (2010-2022) using relevant keywords to identify primary literature in support of current strategies for wound complication prevention and management following spine tumor surgery. When primary literature specific to spine tumor cases was not available, data were extrapolated from studies of other spine surgery populations. Results were compiled into a proposed clinical algorithm to guide practice considering available evidence. RESULTS:Based on available literature, we recommend individualized stratification of patients according to identifiable risk factors for wound complication and propose several interventions which might be employed preventatively, including intrawound antibiotic administration, negative pressure wound therapy, and primary flap closure of the surgical wound. Of these, the available evidence, weighing possible risks vs benefits, most strongly favors primary flap closure of surgical wounds, particularly for patients with multiple risk factors. A secondary algorithm to guide management of wound complications is also proposed. CONCLUSIONS:Wound complications such as SSI and dehiscence remain a significant source of morbidity following spine tumor surgery. Triaging patients on an individualized basis according to risk factors for complication may aid in selecting appropriate prophylactic strategies to prevent these complications. Future research in this area is still needed to strengthen recommendations.
PMCID:11726526
PMID: 39801119
ISSN: 2192-5682
CID: 5775982
Risk Factors for the Development of Neurological Deficits in Metastatic Spinal Disease: An International, Multicenter Delphi Study
STUDY DESIGN/METHODS:Delphi study. OBJECTIVE:The objective of this study was to identify risk factors associated with the development and/or progression of neurological deficits in patients with metastatic spinal disease. METHODS:A three-round Delphi study was conducted between January-May 2023 including AO Spine members, comprising mainly neurosurgeons and orthopedic surgeons. In round 1, participants listed radiological factors, patient characteristics, tumor characteristics, previous cancer-related treatment factors and additional factors. In round 2, participants ranked the factors on importance per category and selected a top 9 from all factors. Kendall's W coefficient of concordance was calculated as a measure of consensus. In the final round, participants provided feedback on the rankings resulting from round 2. Lastly, the highest-ranking factors were more clearly defined and operationalized by an expert panel. RESULTS:Over two hundred physicians and researchers participated in each round. The factors listed in the first round were collapsed into 12 radiological factors, 14 patient characteristics, 6 tumor characteristics and 12 previous cancer-related treatment factors. High agreement was found in round 3 on the top-half lists in each category and the overall top 9, originating from round 2. Kendall's W indicated strong agreement between the participants. 'Epidural spinal cord compression', 'aggressive tumor behavior' and 'mechanical instability' were deemed most influential for the development of neurological deficits. CONCLUSION/CONCLUSIONS:This study provides factors that may be related to the development and/or progression of neurological deficits in patients with metastatic spinal disease. This list can serve as a basis for future directions in prognostication research.
PMCID:11726512
PMID: 39801123
ISSN: 2192-5682
CID: 5776042
What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?
STUDY DESIGN/METHODS:Systematic review. OBJECTIVE:In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries. METHODS:Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications. RESULTS:Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation. CONCLUSION/CONCLUSIONS:In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.
PMID: 39801116
ISSN: 2192-5682
CID: 5775922
Overview of Molecular Prognostication for Common Solid Tumor Histologies - What the Surgeon Should Know
STUDY DESIGN/METHODS:Narrative Literature review. OBJECTIVE:To provide a general overview of important molecular markers and targeted therapies for the most common neoplasms (lung, breast, prostate and melanoma) that metastasize to the spine and offer guidance on how to best incorporate them in the clinical setting. METHODS:A narrative review of the literature was performed using PubMed, Google Scholar, Medline databases, as well as the histology-specific National Comprehensive Cancer Network guidelines to identify relevant articles limited to the English language. Relevant articles were reviewed for commonly described molecular mutations or targeted therapeutics, as well as associated clinical outcomes, and surgery-related risks. RESULTS:Molecular markers and targeted therapies have dramatically improved the survival of cancer patients. The increasing importance of prognostic molecular markers and targeted therapies provides rationale for their incorporation into clinical decision-making for patients diagnosed with metastatic spine disease. In this review, we discuss the molecular markers/mutations and targeted therapies associated with the most common malignancies that metastasize to the spine and provide a framework that the surgeon can utilize when evaluating patients for potential intervention. Finally, we provide case examples that highlight the importance of molecular prognostication and therapies in surgical decision-making. CONCLUSION/CONCLUSIONS:An integrated understanding of the implications of surgery, radiation, molecular markers and targeted therapies that guide prognostication and treatment is warranted in order to achieve the most favorable outcomes for patients with metastatic spine disease.
PMCID:11726510
PMID: 39801124
ISSN: 2192-5682
CID: 5776062
Spine MRI Identifies Clinically Relevant Findings in Patients With Cancer Presenting With Back Pain
STUDY DESIGN/METHODS:This is a retrospective, cross-sectional study. OBJECTIVE:The primary aim was to identify the diagnostic yield of spine magnetic resonance imaging (MRI) in detecting malignant pathology in cancer patients with back pain. We also sought to evaluate the role of MRI extent ( i.e. regional vs. total) in identifying malignant pathology. SUMMARY OF BACKGROUND DATA/BACKGROUND:No prior study has systematically investigated the yield of spine MRI in a large cohort of cancer patients. METHODS:Spine MRI reports from 2017 to 2021 for back pain (acute and nonspecified chronicity) in cancer patients were reviewed to identify clinically relevant findings: malignant (1) epidural, (2) leptomeningeal, (3) intramedullary, (4) osseous disease, and (5) fracture. Logistic regression was used to evaluate the association between MRI extent and the presence of cancer-related findings. For patients with multiple MRIs, short-interval scans (≤4 mo) were evaluated to assess the yield of repeat imaging. RESULTS:At least one cancer-related finding was identified on 52% of 5989 spine MRIs ordered for back pain and 57% of 1130 spine MRIs ordered specifically for acute back pain. The most common pathology was malignant osseous disease (2545; 43%). Across all five categories, most findings (77%-89%) were new/progressive. Odds of identifying a finding were significantly higher with total versus regional spine MRIs ( P <0.001). Although only 14 patients had a positive regional MRI followed shortly by a positive total spine MRI, most of these repeat total spine MRIs (78%) identified findings outside the scope of the initial regional scan. Twenty-one patients had both computed tomography and MRI within 30 days of each other; eight (38%) had compression fractures appreciated on MRI but not on computed tomography. CONCLUSIONS:Our findings suggest imaging the total spine in cancer patients with back pain given higher odds of identifying malignant pathology and instances of capturing otherwise not visualized disease. Further work is warranted to confirm these findings.
PMCID:10879457
PMID: 37602415
ISSN: 1528-1159
CID: 5892272
Management of Refractory Cancer Pain with Intrathecal Drug Delivery and Spinal Cord Stimulation
BACKGROUND/UNASSIGNED:Intrathecal pumps (ITPs) are indicated for refractory cancer pain and decrease systemic opioid requirements. While not yet indicated for cancer pain, spinal cord stimulators (SCSs) are used off-label for cancer pain, with increasing evidence of their efficacy. MATERIALS AND METHODS/UNASSIGNED:A retrospective chart review was conducted of patients who underwent both ITP and at least SCS trial for cancer pain. Primary outcomes were pain numeric rating scale (NRS) and daily morphine equivalents (MEQs). RESULTS/UNASSIGNED:Seventeen patients were identified. Both ITP and SCS were associated with significant decreases in pain ratings at the 3-month follow-up, but this decrease became nonsignificant subsequently. ITP, but not SCS, was associated with a significant decrease in MEQ. CONCLUSIONS/UNASSIGNED:ITP and SCS may both provide efficacy for cancer pain, but the opioid-sparing effects of SCS may be limited. ITP and SCS may potentially be complementary in their ability to provide relief from cancer-related pain.
PMCID:11319851
PMID: 39144131
ISSN: 2689-2820
CID: 5892282
Canadian journal of surgery = Journal canadien de chirurgie. 2024:67(6suppl1):S17-S76.DOI: 10.1503/cjs.011424
Canadian Spine Society: 24th Annual Scientific Conference, Wednesday, February 28 - Saturday, March 2, Fairmont Chateau Whistler, Whistler, B.C., Canada
PMID: 39537311
ISSN: 1488-2310
CID: 5753252
