Cost effectiveness and outcome assessment of magnetic resonance imaging in diagnosing cord compression

Evaluating the Clinical Utility and Cost of Imaging Strategies in Adults with Newly Diagnosed Primary Intradural Spinal Tumors

OBJECTIVE

In patients with new primary intradural spinal tumors, the best screening strategy for additional central nervous system (CNS) lesions is unclear. The goal of this study was to document the rate of additional CNS tumors in these patients.

METHODS

Adults with primary intradural spinal tumors were retrospectively reviewed. Imaging strategy at diagnosis was classified as focused spine (cervical, thoracic, or lumbar), total spine, or complete neuraxis (brain and total spine). Tumor pathology, genetic syndromes, and presence of additional CNS lesions at diagnosis or follow-up were collected.

RESULTS

The study comprised 319 patients with mean age of 51 years and mean follow-up of 41 months. In 151 patients with focused spine imaging, 3 (2.0%) were found to have new lesions with 2 (1.4%) requiring treatment. In 35 patients with total spine imaging, there were no additional lesions. In 133 patients with complete neuraxis imaging, 4 (3.0%) were found to have new lesions with 2 (1.5%) requiring treatment. There was no difference in the identification of new lesions (P = 0.542) or new lesions requiring treatment (P = 0.772) across imaging strategies. Among patients without genetic syndromes, rates of new lesions requiring treatment were 1.4% for focused spine, 0% for total spine, and 2.2% for complete neuraxis (P = 0.683). There were no cases of delayed identification causing risk to life or neurological function. Complete neuraxis imaging carried an increased charge of $4420 per patient.

CONCLUSIONS

Among patients without an underlying genetic syndrome, the likelihood of identifying additional CNS lesions requiring treatment is low. In appropriate cases, focused spine imaging may be a more cost-effective strategy.

Management of Metastatic Spinal Cord Compression

Metastatic spinal cord compression, diagnosed in 3–7% of cancer patients, is one of the most dreaded complications of metastatic cancer. It is an oncologic emergency, which must be diagnosed early and treated promptly to achieve the best results and avoid progressive pain, paralysis, sensory loss and sphincter incontinence. Patients who are ambulatory at the time of the diagnosis have a higher probability of obtaining good response to treatment and a longer survival. In clinical practice, back pain accompanies metastatic spinal cord compression in most cases, even in patients with no neurologic deficits. Magnetic resonance imaging is the best tool for diagnosing metastatic spinal cord compression and is able to identify spinal cord compression in 32–35% patients with back pain, bone metastases and normal neurologic examination. Moreover, magnetic resonance imaging gives the extension of the lesion, can diagnose other unsuspected clinical metastatic spinal cord compression sites, and is useful for the radiation oncologist in defining the target volume. Radiotherapy is the treatment of choice in most cases, whereas surgery is advised only in selected patients (ie, if stabilization is necessary, if radiotherapy has already been given in the same area, when vertebral body collapse causes bone impingement on the cord or nerve roots, when there are diagnostic doubts, or when computed tomography-guided percutaneous vertebral biopsy cannot be performed). Laminectomy should be abandoned in favor of more aggressive surgery (ie, posterior, anterior, and/or lateral approach, tumor mass resection, and stabilization of the spine). Generally, radiotherapy must be administered 7–10 days after surgery. The optimal radiation schedule has not been defined. However, as recently suggested by some clinical trials, even the hypofractionated radiotherapy regimens are effective and can be used without increasing radiation-induced myelopathy. Moderate doses of dexamethasone should be used in the early phases of therapy. After radiotherapy, spinal recurrence is generally found in sites different from the first compression area. A close post-treatment follow-up is suggested using clinical parameters (pain, motor and sphincter function), and magnetic resonance imaging should be performed only when a second metastatic spinal cord compression and/or myelopathy are clinically suspected.

Does choice of imaging modality affect outcome in dogs with thoracolumbar spinal conditions?

OBJECTIVES

A retrospective cross-sectional study was done to look for differences in outcome in canine spinal patients that had myelography compared to those that had magnetic resonance imaging.

METHODS

Medical records of dogs with spinal conditions in the period January 2004 to December 2007 were reviewed. Data on patient age, gender, breed, size, neurolocalisation, rate of onset, imaging modality, time taken to image, type of treatment, neurological grade at admission and discharge, length and cost of hospitalisation and status at discharge were collected. Only dogs with neurological grade 3 to 6 with signs referable to the thoracolumbar spine were included.

RESULTS

Of 107 dogs that met the inclusion criteria, 66 (62%) had myelography and 41 (38%) had magnetic resonance imaging. Using multivariable analyses, non-chondrodystrophoid breed, increasing age and higher neurological grade at admission were found to be associated negatively with survival. Neurological grade 5 at admission was found to be associated positively with likelihood of neurological improvement. Male gender, higher neurological grade at admission and medical treatment were associated negatively with length of hospitalisation. magnetic resonance imaging, surgical treatment and period of hospitalisation were associated positively with total cost of hospitalisation.

CLINICAL SIGNIFICANCE

No significant association was found between type of imaging and any patient outcome variables except cost of hospitalisation, which was higher for dogs having magnetic resonance imaging. Although magnetic resonance imaging may be considered advantageous compared to myelography because it is non-invasive and provides superior anatomical detail for surgical guidance, no beneficial effect on outcome of dogs with non-ambulatory thoracolumbar spinal disease was found.

Short-Course Versus Split-Course Radiotherapy in Metastatic Spinal Cord Compression: Results of a Phase III, Randomized, Multicenter Trial

Purpose

Hypofractionated radiotherapy (RT) is often used in the treatment of metastatic spinal cord compression (MSCC). This randomized trial was planned to assess the clinical outcome and toxicity of two different hypofractionated RT regimens in MSCC.

Patients and Methods

Three hundred patients with MSCC were randomly assigned to a short-course RT (8 Gy × 2 days) or to a split-course RT (5 Gy × 3; 3 Gy × 5). Only patients with a short life expectancy entered the protocol. Median follow-up was 33 months (range, 4 to 61 months).

Results

A total of 276 (92%) patients were assessable; 142 (51%) treated with the short-course and 134 (49%) treated with the split-course RT regimen. There was no significant difference in response, duration of response, survival, or toxicity found between the two arms. When short- versus split-course regimens were compared, after RT 56% and 59% patients had back pain relief, 68% and 71% were able to walk, and 90% and 89% had good bladder function, respectively. Median survival was 4 months and median duration of improvement was 3.5 months for both arms. Toxicity was equally distributed between the two arms: grade 3 esophagitis or pharyngitis was registered in four patients (1.5%), grade 3 diarrhea occurred in four patients (1.5%), and grade 3 vomiting or nausea occurred in 10 patients (6%). Late toxicity was never recorded.

Conclusion

Both hypofractionated RT schedules adopted were effective and had acceptable toxicity. However, considering the advantages of the short-course regimen in terms of patient convenience and machine time, it could become the RT regimen of choice in the clinical practice for MSCC patients.

Hematologic and oncologic emergencies. Doing the most good in the least time

Broad categories of emergency hematologic and oncologic situations are metabolic crises, compressions and obstructions, and symptomatic cytopenias. In each instance, a decision to intervene should be made on the basis of findings on diagnostic assessment in combination with prognostic information. Management should be directly proportional to the possibility for cure, significant remission, or improved quality of life. Numerous diseases, including potentially curable cancer, can be modified and patients' quality of life substantially improved with appropriate emergency intervention. Fortunately, the modern therapeutic arsenal provides many specific measures to manage these challenging clinical situations.

Metastatic epidural spinal cord compression

OBJECTIVES

To provide an overview on the presentation, diagnosis, and treatment of metastatic epidural spinal cord compression (MESCC).

DATA SOURCES

Published articles, book chapters, and research reports.

CONCLUSIONS

MESCC is a common oncologic emergency that requires prompt recognition and emergency treatment to relieve pain and preserve neurologic function. The signs and symptoms of MESCC are easily detected and can be integral assessment components of the nursing care of any patient with a solid tumor.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can have a dramatic impact on preventing neurologic complications caused by this oncologic metastatic problem. When neurologic compromise is not prevented or reversed, nurses also can provide expert care to patients and families in the rehabilitation phase of MESCC.

Economic analyses of radiological procedures: a methodological evaluation of the medical literature

OBJECTIVE

Increasing pressure to curb health care costs has led to considerable interest in economic analyses, including both cost-effectiveness and cost-benefit analyses. Numerous economic analyses of radiological procedures have appeared in both the radiology and non-radiology literature. The objective of this study was to evaluate the methodological quality of economic analyses of radiological procedures published in the non-radiology medical literature during the years 1990 1995.

METHODS

Original investigations from the medical (non-radiological) literature that include economic analyses of radiological interventions were identified from a computerized literature search. Each economic analysis article was evaluated by two independent reviewers for adherence to ten methodological criteria. The criteria were derived from review of the medical and radiological economic analysis methodology literature and consisted of the following: (1) Comparative options stated; (2) perspective of analysis defined; (3) outcome measure identified; (4) cost data included; (5) source of cost data stated; (6) long term costs included; (7) discounting employed; (8) summary measure provided; (9) incremental computation method used; and (10) sensitivity analysis performed. The results were compared to a previous study that evaluated the radiological literature.

RESULTS

Of the 56 articles in the medical literature that included economic analyses of radiological procedures, only eight (14%) conformed to all ten methodological criteria. The cost data (98%) and comparative options (89%) criteria exhibited high compliance, while the perspective of analysis (25%) and discounting (32%) criteria had relatively low compliance. Agreement between the reviewers was excellent (kappa = 0.88).

CONCLUSIONS

Published economic analyses of radiology procedures usually do not meet accepted methodological standards.