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Debono B, Perez A, Lonjon G, Hamel O, Dandine JB, Dupuy M, Dutertre G, Braticevic C, Latorzeff I, Amelot A. Enhancing the referral process for surgical management of spinal metastases: insights from a 12-year, bi-institutional study of 533 patients. Front Oncol 2024; 14:1301305. [PMID: 38352892 PMCID: PMC10861661 DOI: 10.3389/fonc.2024.1301305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/16/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction Delayed surgical management of spinal metastases (SMs) can have detrimental effects on patient survival and quality of life, leading to pain and potential neurological impairment. This study aimed to assess the impact of delayed referral for SMs on clinical outcomes by analyzing patients managed in emergency situations. Methods We retrospectively reviewed the data of all patients admitted on either emergency or elective basis who underwent surgery for the treatment of neoplastic spine lesions at our two institutions (tertiary referral neurosurgical units) between January 2008 and December 2019. Results We analyzed 210 elective (EGp) and 323 emergency patients (UGp); emergencies increased significantly over the 12-year period, with a Friday peak (39.3%) and frequent neurological impairment (61.6% vs. 20%). Among the UGp patients, 186 (7.5%) had a previously monitored primitive cancer, including 102 (31.6%) with known SMs. On admission, 71 of the 102 (69.9%) patients presented with neurological deficits. UGp patients were more likely to undergo a single decompression without fixation. Outcomes at the 3-month follow-up were significantly worse for UGp patients ([very] poor, 29.2 vs. 13.8%), and the median overall survival for UGp patients was statistically lower. Risk factors for patients with SM undergoing emergency management included short delay between onset of symptoms and first contact with a spine surgeon, and an initial motor deficit. Conclusion Many patients with previously identified metastases, including those with neurological deficits, are urgently referred. Optimization is needed in the oncology pathway, and all stakeholders must be made aware of the factors contributing to the improvement in the clinical and radiological identification of potential complications affecting patient survival and quality of life.
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Affiliation(s)
- Bertrand Debono
- Department of Neurosurgery, Paris-Versailles Spine Center, Hôpital privé de Versailles, Versailles, France
| | - Alexis Perez
- Department of Neurosurgery, Clinique de l’Union, Toulouse, France
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean-Sud de France, Santé Cite Group, Montpellier Metropole, France
| | - Olivier Hamel
- Department of Neurosurgery, Clinique des Cédres, Toulouse, France
| | | | - Martin Dupuy
- Department of Neurosurgery, Clinique de l’Union, Toulouse, France
| | - Guillaume Dutertre
- Institut Curie, Paris Sciences et Lettres (PSL) Research University, Surgical Oncology Department, Paris, France
| | - Cécile Braticevic
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Igor Latorzeff
- Department of Radiotherapy, Groupe ONCORAD Garonne, Clinique Pasteur, Toulouse, France
| | - Aymeric Amelot
- Department of Neurosurgery, Hopital Bretonneau, Tours, France
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Ahuja S, Shah P, Mohammed R. Impact of COVID-19 pandemic on acute spine surgery referrals to UK tertiary spinal unit: any lessons to be learnt? Br J Neurosurg 2020; 35:181-185. [PMID: 33764256 DOI: 10.1080/02688697.2020.1777263] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Evidence is emerging, suggesting a significant drop in hospital referrals and attendances for various medical conditions due to the COVID-19 pandemic. With the implementation of lockdown rules, road traffic and outdoor activities were expected to drop, thereby reducing the number of high-energy spinal injuries. Critical non-traumatic spinal conditions like spinal tumours, infections, or compressive pathologies, however, should continue to present as before. We assessed all acute spinal referrals to our tertiary spine unit comparing with the acute activity for a similar time frame in the previous year. The aim was to identify any variance in the acute spinal activity, explain reasons for the discrepancy and identify any learning points. MATERIALS All acute referrals to our tertiary spinal surgery unit made from 01 February 2020 to 30 April 2020 were evaluated. Similar data from the preceding year, i.e. 2019 was evaluated for comparison. Data were analysed for qualitative or quantitative changes in the referral pattern and their subsequent management outcomes. RESULTS Spinal referral numbers reduced by 46.05% during the time frame of February-April 2020 when compared to the same period in 2019 (p < 0.017). Similarly, numbers of high-energy traumatic presentations reduced by 72% (p < 0.002). Referrals for critical spinal conditions declined by two-thirds for spinal infections and more than a third for spinal tumours. Emergency surgical workload waned by 27%, especially more so during the six-week lockdown duration. CONCLUSION Reduction in spinal activity, even for critical spinal conditions, during the pandemic is likely due to a combination of factors like patient behaviour, fear of contracting COVID-19 infection during hospital visit, self-isolation advice, availability of a senior decision maker on the frontlines, and changes in healthcare service provisions. The health crisis may provide an opportunity for optimisation of spinal healthcare services both at the referring hospital and at the tertiary centre.
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Affiliation(s)
- Sashin Ahuja
- Welsh Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Pranav Shah
- Welsh Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Riaz Mohammed
- Welsh Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff, UK
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Debono B, Braticevic C, Sabatier P, Dutertre G, Latorzeff I, Hamel O. The "Friday peak" in surgical referrals for spinal metastases: lessons not learned. A retrospective analysis of 201 consecutive cases at a tertiary center. Acta Neurochir (Wien) 2019; 161:1069-1076. [PMID: 31037499 DOI: 10.1007/s00701-019-03919-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/18/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Spinal cord compression and fracture are potential complications of spine metastasis (SM). Rapid management by an expert team can reduce these adverse developments. Delays in seeking therapeutic advices, which lead to the need for sub-optimal emergency procedures, were already demonstrated nearly 20 years ago. We aimed to analyze the current weak points of referrals for vertebral metastasis so as to improve the care pathways. METHODS We retrospectively reviewed the data of all patients admitted on an emergency or elective basis who underwent palliative surgery for the treatment of neoplastic spine lesions in our institution (tertiary referral neurosurgical unit) between January 2009 and December 2016. RESULTS This retrospective study included 201 patients, 121 men and 80 women (mean age 65.1 years ± 10.9). Cancer was known for 59.7% of cases. Patients were neurologically asymptomatic in 52.7% of cases (Frankel E), and 123 (60.7%) were hospitalized for emergency reasons, including 51 (41.5% of emergencies) on a Friday (p < 0.0001). A significant increase in emergencies occurred over the studied period (p = 0.0027). The "emergency" group had significantly unfavorable results in terms of neurological status (p < 0.001), the occurrence of complications (p = 0.04), the duration of hospitalization (p = 0.02), and the clinical evolution (p = 0.04). Among 123 patients hospitalized for emergency reasons, 65 (52.8%) had known cancers, of which 33 had an identified SM, including 22 with neurological deficits (Frankel A-D), without prior surgical assessment (17.8% of emergencies). CONCLUSION Too many patients with previously identified metastases are referred for emergency reasons, including with a neurological deficit. Optimizing upstream pathways and referrals is imperative for improving the management of these patients. Involving a spine surgeon at the slightest symptom or an abnormal image is critical for defining the best treatment upstream. The use of telemedicine and the development of dedicated tumor boards are ways of improving this involvement.
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Affiliation(s)
- Bertrand Debono
- Department of Neurosurgery, Neuroscience Pole, Capio - Clinique des Cèdres, 31700, Cornebarrieu, France.
| | - Cécile Braticevic
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Pascal Sabatier
- Department of Neurosurgery, Neuroscience Pole, Capio - Clinique des Cèdres, 31700, Cornebarrieu, France
| | - Guillaume Dutertre
- Surgical Oncology Department, Institut Curie, PSL Research University, Paris, France
| | - Igor Latorzeff
- Department of Radiotherapy, Groupe ONCORAD Garonne, Clinique Pasteur, Toulouse, France
| | - Olivier Hamel
- Department of Neurosurgery, Neuroscience Pole, Capio - Clinique des Cèdres, 31700, Cornebarrieu, France
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Bunevicius A, Tamasauskas A, Ambrozaitis KV. Spontaneous thoracic subdural hematoma associated with warfarin therapy: Case report with serial MRI. Surg Neurol Int 2019; 10:28. [PMID: 31528366 PMCID: PMC6499461 DOI: 10.4103/sni.sni_384_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022] Open
Abstract
Background: Spontaneous acute spinal subdural hematoma (SASSDH) is a rare but serious condition. We present diagnostic challenges and serial magnetic resonance imaging (MRI) findings of a patient who developed warfarin-associated thoracic SASSDH that was managed surgically. Case Description: A 68-year-old male presented with sudden onset left-sided chest and back pain, left leg weakness, and bilateral loss of sensations below T4 level. His symptoms developed after strenuous physical activity. He was taking warfarin for atrial fibrillation. His admission international normalized ratio was 4.25. Deterioration of neurological status 3 days after admission prompted spinal computed tomography (CT) scan that demonstrated nonhomogenous hyperdense intradural mass lesion in the thoracic spine. MRI demonstrated heterogeneous mass lesion on the left side of the spinal canal and thoracic myelopathy. The patient underwent urgent surgical evacuation of subacute subdural hematoma extending from T3 to T6 levels. MRI scan following the surgery showed no signs of the hematoma and thoracic myelopathy. MRI at 3 months follow-up demonstrated myelopathy extending from T3 to T6 levels with deviation of the spinal cord. The patient's motor strength and sensations improved but he retained left leg weakness with sensory deficit below T8 level. Conclusions: Spinal subdural hematoma should be suspected in patients presenting with acute onset back pain and myelopathy in the absence of trauma history. Coagulopathy should raise the suspicion for SASSDH. MRI is a valuable imaging modality for initial diagnosis to rule-out other lesions, and to assess postoperative re-bleeding and residual lesions.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania.,Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Arimantas Tamasauskas
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania.,Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kazys Vytautas Ambrozaitis
- Department of Neurosurgery, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
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Pereira BJA, de Almeida AN, Muio VMF, de Oliveira JG, de Holanda CVM, Fonseca NC. Predictors of Outcome in Nontraumatic Spontaneous Acute Spinal Subdural Hematoma: Case Report and Literature Review. World Neurosurg 2016; 89:574-577.e7. [DOI: 10.1016/j.wneu.2015.11.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 11/06/2015] [Accepted: 11/06/2015] [Indexed: 12/19/2022]
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Gupta AK, Stewart SK, Cottell K, McCulloch GAJ, Babidge W, Maddern GJ. Potentially avoidable issues in neurosurgical mortality cases in Australia: identification and improvements. ANZ J Surg 2016; 87:86-91. [DOI: 10.1111/ans.13542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/14/2016] [Accepted: 02/22/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Aashray K. Gupta
- South Australian Audit of Perioperative Mortality (SAAPM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Sasha K. Stewart
- South Australian Audit of Perioperative Mortality (SAAPM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Kimberley Cottell
- South Australian Audit of Perioperative Mortality (SAAPM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Glenn A. J. McCulloch
- South Australian Audit of Perioperative Mortality (SAAPM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Wendy Babidge
- University of Adelaide Discipline of Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
- Australian and New Zealand Audit of Surgical Mortality (ANZASM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
| | - Guy J. Maddern
- University of Adelaide Discipline of Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
- Australian and New Zealand Audit of Surgical Mortality (ANZASM); Royal Australasian College of Surgeons; Adelaide South Australia Australia
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Tazi H, Manunta A, Rodriguez A, Patard JJ, Lobel B, Guillé F. Spinal Cord Compression in Metastatic Prostate Cancer. Eur Urol 2003; 44:527-32. [PMID: 14572749 DOI: 10.1016/s0302-2838(03)00355-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Spinal cord compression (SCC) in metastatic prostate cancer is not rare occurring in 1 to 12% of patients. We have analysed patients treated for this condition in our institution assessing outcome and prognostic factors. MATERIAL AND METHODS Retrospective analysis of the notes of 24 patients hospitalised with SCC due to metastatic prostate cancer from 1987 to 2001. RESULTS At presentation 3 patients were ambulant with mild neurological deficit, 12 patients were paraparetic and 9 patients were paraplegic. Diagnosis was established by emergency myelogram, CT-scan or MRI of the spine. 8 patients had received no hormone treatment prior to diagnosis of SCC. 19 patients presented dorsal or lumbar pain requiring opioid treatment on average 60 days before onset of neurological symptoms (range 10-840). All patients underwent steroid treatment; the 8 patients without prior hormone therapy were treated with bilateral orchidectomy, 1 out of these 8 patients had castration without other treatments; 12 patients underwent radiotherapy alone and 9 radiotherapy and laminectomy; 2 patients were in terminal conditions and receive only steroid treatment. Overall 15/24 patients were ambulant after treatment. 8 out of 9 patients treated by laminectomy and radiotherapy were ambulant after treatment versus 7 out of 12 patients treated by radiotherapy alone.17 patients died during follow-up with a median survival of 4 months (2 weeks to 49 months). 7 patients were alive at the last control with a mean follow-up of 10 months (range 4-40). CONCLUSION Outlook in patients with spinal cord compression from metastatic prostate cancer is poor. Efforts must be concentrated on prevention of spinal cord compression. Patients with hormone resistant prostate cancer who develop persistent back pain should undergo imaging studies (bone scan, spine CT-scan or MNR) and prophylactic local radiotherapy to the spine if bony metastases are identified.
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Affiliation(s)
- H Tazi
- Service d'Urologie, Centre Hospitalier Universitaire Pontchaillou, Rue Henri Le, Guilloux, 35033 Cedex, Rennes, France
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Langmayr JJ, Ortler M, Dessl A, Twerdy K, Aichner F, Felber S. Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression. J Neurol Neurosurg Psychiatry 1995; 59:442-7. [PMID: 7561928 PMCID: PMC486085 DOI: 10.1136/jnnp.59.4.442] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Spinal cord compression due to extradural and subdural haemorrhage is a neurosurgical emergency. Differences in clinical presentation in relation to localisation of the haematoma, value of MRI as a diagnostic tool, surgical treatment, and prognosis were investigated in a retrospective case series of eight patients with extradural (n = four) and subdural (n = four) haematomas. Results of MRI were compared with operative findings and proved to be of high sensitivity in defining the type of bleeding and delineating craniocaudal extension and ventrodorsal location. Surgical treatment by decompressive laminectomy, haematoma evacuation, and postoperative high dose corticosteroids resulted in resolution of symptoms in five patients and improvement in the clinical situation in two patients. One patient with a chronic subdural haematoma had a second operation because of arachnoidal adhesions. One patient presented with a complete cord transection syndrome due to an acute subdural haematoma and remained paraplegic. It is concluded that prompt, reliable, and non-invasive diagnosis by MRI leads to efficient surgical treatment and a favourable outcome in this rare condition.
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Affiliation(s)
- J J Langmayr
- Universitätsklinik für Neurochirurgie, Innsbruck, Austria
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Perkin GD. More doctors. J Neurol Neurosurg Psychiatry 1995; 59:447. [PMID: 7561929 PMCID: PMC486086 DOI: 10.1136/jnnp.59.4.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- G D Perkin
- Regional Neurosciences Centre, Charing Cross Hospital, London, UK
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11
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Proceedings of the 122nd Meeting of the Society of British Neurological Surgeons, Nottingham, 26-28 May 1993. J Neurol Psychiatry 1993. [DOI: 10.1136/jnnp.56.12.1330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Affiliation(s)
- R A Johnston
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, UK
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13
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Rosenthal MA, Rosen D, Raghavan D, Leicester J, Duval P, Besser M, Pearson B. Spinal cord compression in prostate cancer. A 10-year experience. BRITISH JOURNAL OF UROLOGY 1992; 69:530-3. [PMID: 1320441 DOI: 10.1111/j.1464-410x.1992.tb15603.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Of 478 patients treated at a single institution for prostate cancer, 29 developed spinal cord or cauda equina compression. In 5 patients, spinal cord compression was the first evidence of malignancy. Clinical features were predominantly pain, weakness, sensory and sphincter disturbance. The median duration of symptoms was 2 weeks, although the diagnosis was made rapidly at presentation. Clinical diagnosis correlated well with myelographic findings. Only 1 patient suffered neurological deterioration as a consequence of myelography. The functional outcome was dependent on the ability to walk prior to treatment. The median survival in those who were bedridden following treatment was 6 weeks (range 3.5-13) and 21 weeks (range 7-110+) in those who were ambulant following therapy.
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Affiliation(s)
- M A Rosenthal
- Urological Cancer Research Unit, Royal Prince Alfred Hospital, Sydney, Australia
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15
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Affiliation(s)
- A N Gale
- Department of Neurological Science, Royal Free Hospital School of Medicine, London, UK
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Johnston R. Spinal surgery. J Neurol Neurosurg Psychiatry 1990; 53:1021-3. [PMID: 2292690 PMCID: PMC488306 DOI: 10.1136/jnnp.53.12.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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