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Kumar N, Lee EXY, Hui SJ, Kumar L, Jonathan Tan JH, Ashokka B. Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts. Global Spine J 2024:21925682231167096. [PMID: 38453667 DOI: 10.1177/21925682231167096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. METHODS A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. RESULTS A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. CONCLUSION Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Naresh Kumar
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Si Jian Hui
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Laranya Kumar
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Jiong Hao Jonathan Tan
- University Spine Centre, Department of Orthopaedic Surgery, National University Health System, Singapore
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Qiao R, Ma R, Zhang X, Lun D, Li R, Hu Y. Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis. Eur Spine J 2023; 32:4272-4296. [PMID: 37661228 DOI: 10.1007/s00586-023-07898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. METHODS A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. RESULTS The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3 mL in the NE group and 1716.4 mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15 mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). CONCLUSIONS PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.
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Affiliation(s)
- Ruiqi Qiao
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China
| | - Rongxing Ma
- Graduate School, Tianjin Medical University, Tianjin, China
| | | | - Dengxing Lun
- Department of Bone Oncology, Weifang People's Hospital, Weifang, China
| | - Ruifeng Li
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yongcheng Hu
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China.
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Motov S, Stengel F, Ringel F, Bozinov O, Stienen MN. Current state of preoperative embolization for spinal metastasis - A survey by the EANS spine section. Brain Spine 2023; 3:102712. [PMID: 38021014 PMCID: PMC10668085 DOI: 10.1016/j.bas.2023.102712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers. Research question The aim was to understand the current decision-making process in European spine centers. Material and methods The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023. Results We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13). Discussion and conclusions PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications.
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Affiliation(s)
- Stefan Motov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Felix Stengel
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Florian Ringel
- University Hospital Mainz & Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
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Maddy K, Trenchfield D, Destine H, Waiters V, Nwatu D, Lucke-Wold B. Spinal tumor embolization: benefit for surgical resection. BOHR Int J Neurol Neurosci 2023; 1:71-80. [PMID: 37576947 PMCID: PMC10421648 DOI: 10.54646/bijnn.2023.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The embolization of hypervascular spinal tumors preoperatively has shown to be a worthwhile adjunctive procedure to minimize the elevated risks associated with surgical resection, such as intraoperative blood loss and its associated complications. Resection of these hypervascular tumors is necessary for local tumor control, reduction in patient-reported pain, improved neurological functioning, and spinal stability. This adjunctive procedure has been associated with improved surgical outcomes and easier facilitation of surgical resection. As such, we provide a review of the current literature examining the employment of this technique. Specifically, this article (a) reviews the techniques of embolization, with anatomical considerations of the arterial framework of the spinal network; (b) relativizes and outlines the post-embolization management of spinal tumor resection; (c) provides a critical outlook on the reported benefit of preoperative embolization before surgical resection with support from clinical studies in the literature; and (d) discusses the efficacy and reliability of provocative testing and post-procedural management and follow-up. Ultimately, a thorough and updated review of preoperative spinal tumor embolization and its clinical benefits will summarize the current fund of knowledge and encourage future research toward continued improvements in patient outcomes for those needing to undergo surgical resection of spinal lesions.
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Affiliation(s)
- Krisna Maddy
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Henson Destine
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Daniel Nwatu
- University of Miami Miller School of Medicine, Miami, FL, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
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Huang YC, Tsuang FY, Lee CW, Lin YH. Efficacy of preoperative embolization for metastatic spinal tumor surgery using angiographic vascularity assessment. Eur Radiol 2023; 33:2638-2646. [PMID: 36449062 DOI: 10.1007/s00330-022-09276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/22/2022] [Accepted: 10/27/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVES Preoperative embolization (PE) for metastatic spinal tumors is a method of minimizing intraoperative blood loss during aggressive surgery. This study specified angiographic standards and investigated the influence of these and other factors on blood loss in patients with spinal metastases and various pathologies. METHODS The cohort comprised 126 consecutive patients receiving PE from 2015 to 2021. Their clinical, surgical, and angiographic characteristics were reviewed. Standard angiographic grading was used for vascularity assessment. Degree of embolization was divided into complete (≥ 90%), near complete (67 to < 90%), and partial (< 67%). Logistic regression analysis was used to investigate factors predictive of massive blood loss (> 2500 mL). A proportional odds model was used to assess factors predictive of the degree of embolization. RESULTS Mean intraoperative blood loss was 1676 mL. Among the patients, 62 had hypervascular tumors and 64 had nonhypervascular tumors, according to the angiographic classification. Intraoperative blood loss differed significantly with embolization degree, both overall (p < 0.001) and in the hypervascular and nonhypervascular groups (p = 0.01 and 0.03). Angiographic hypervascularity, spinal metastasis invasiveness index, and embolization degree were significant predictors of massive blood loss in univariate analysis, but only embolization degree was significant in multivariate analysis. Only the presence of the radiculomedullary artery at the target level was significant in both the univariate and multivariate analyses for embolization degree. CONCLUSIONS In addition to pathological classification, angiographic vascularity assessment is valuable. Although complete embolization is a reasonable goal, it is challenging to achieve in cases of visible radiculomedullary artery. KEY POINTS • Angiography has a supplementary role in vascularity assessment for spinal metastatic surgery. • Better embolization degree is associated with less intraoperative blood loss in both angiographic hypervascular and nonhypervascular groups. • Presence of radiculomedullary artery in the target level causes worse embolization outcome.
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Affiliation(s)
- Yu-Cheng Huang
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Fon-Yih Tsuang
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan.
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan.
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Contartese D, Bandiera S, Giavaresi G, Borsari V, Griffoni C, Gasbarrini A, Fini M, Salamanna F. Postoperative Survival and Clinical Outcomes for Uterine Leiomyosarcoma Spinal Bone Metastasis: A Case Series and Systematic Literature Review. Diagnostics (Basel) 2022; 13:diagnostics13010015. [PMID: 36611309 PMCID: PMC9818380 DOI: 10.3390/diagnostics13010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Deyanira Contartese
- Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Correspondence:
| | - Stefano Bandiera
- Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Gianluca Giavaresi
- Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Veronica Borsari
- Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | | | | | - Milena Fini
- Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Salamanna
- Complex Structure of Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Zhang B, Yu H, Zhao X, Cao X, Cao Y, Shi X, Wang Z, Liu Y. Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis. Front Oncol 2022; 12:1098182. [PMID: 36591512 PMCID: PMC9798328 DOI: 10.3389/fonc.2022.1098182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC). Methods A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient's baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization. Results Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss. Conclusions Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.
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Affiliation(s)
- Bin Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China
| | - Haikuan Yu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Chinese PLA Medical School, Beijing, China
| | - Xiongwei Zhao
- Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xuyong Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Yuncen Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Zheng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Yaosheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
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Park HY, Kim YH, Ha KY, Chang DG, Kim SL, Park SB. Are the Choice of Frame and Intraoperative Patient Positioning Associated With Radiologic and Clinical Outcomes in Long-instrumented Lumbar Fusion for Adult Spinal Deformity? Clin Orthop Relat Res 2022; 480:982-992. [PMID: 34904962 PMCID: PMC9007220 DOI: 10.1097/corr.0000000000002084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies of patient positioning during spinal surgery evaluated intraoperative or immediate postoperative outcomes after short-instrumented lumbar fusion. However, patient positioning during long-instrumented fusion for an adult spinal deformity (ASD) might be associated with differences in intraoperative parameters such as blood loss and longer-term outcomes such as spine alignment, and comparing types of surgical tables in the context of these larger procedures and evaluating longer-term outcome scores seem important. QUESTIONS/PURPOSES (1) Do blood loss and the number of transfusions differ between patients who underwent multi-level spinal fusion with a Wilson frame and those with a four-poster frame? (2) Does restoration of lumbar lordosis and the sagittal vertical axis differ between patients who underwent surgery with the use of one frame or the other? (3) Do clinical outcomes as determined by Numeric Rating Scale and Oswestry Disability Index scores differ between the two groups of patients? (4) Are there differences in postoperative complications between the two groups? METHODS Among 651 patients undergoing thoracolumbar instrumented fusion between 2015 and 2018, 129 patients treated with more than four levels of initial fusion for an ASD were identified. A total of 48% (62 of 129) were eligible; 44% (57 of 129) were excluded because of a history of fusion, three-column osteotomy, or surgical indications other than degenerative deformity, and another 8% (10 of 129) were lost before the minimum 2-year follow-up period. Before January 2017, one surgeon in this study used only a Wilson frame; starting in January 2017, the same surgeon consistently used a four-poster frame. Forty patients had spinal fusion using the Wilson frame; 85% (34 of 40) of these had follow-up at least 2 years postoperatively (mean 44 ± 13 months). Thirty-two patients underwent surgery using the four-poster frame; 88% (28 of 32) of these were available for follow-up at least 2 years later (mean 34 ± 6 months). The groups did not differ in terms of age, gender, BMI, type of deformity, or number of fused levels. Surgical parameters such as blood loss and the total amount of blood transfused were compared between the two groups. Estimated blood loss was measured by the amount of suction drainage and the amount of blood that soaked gauze. The decision to transfuse blood was based on intraoperative hemoglobin values, a protocol that was applied equally to both groups. Radiologic outcomes including sagittal parameters and clinical outcomes such as the Numerical Rating Scale score for back pain (range 0-10; minimal clinically important difference [MCID] 2.9) and leg pain (range 0-10; MCID 2.9) as well as the Oswestry Disability Index score (range 0-100; MCID 15.4) were also assessed through a longitudinally maintained database by two spine surgeons who participated in this study. Repeated-measures analysis of variance was used to compare selected radiologic outcomes between the two groups over time. RESULTS Blood loss and the total amount of transfused blood were greater in the Wilson frame group than in the four-poster frame group (2019 ± 1213 mL versus 1171 ± 875 mL; mean difference 848 [95% CI 297 to 1399]; p = 0.003 for blood loss; 1706 ± 1003 mL versus 911 ± 651 mL; mean difference 795 [95% CI 353 to 1237]; p = 0.001 for transfusion). Lumbar lordosis and the sagittal vertical axis were less restored in the Wilson frame group than in the four-poster frame group (7° ± 10° versus 18° ± 14°; mean difference -11° [95% -17° to -5°]; p < 0.001 for lumbar lordosis; -22 ± 31 mm versus -43 ± 27 mm; mean difference 21 [95% CI 5 to 36]; p = 0.009 for the sagittal vertical axis). Such differences persisted at 2 years of follow-up. The proportion of patients with the desired correction was also greater in the four-poster frame group than in the Wilson frame group immediately postoperatively and at 2 years of follow-up (50% versus 21%, respectively; odds ratio 3.9 [95% CI 1.3 to 11.7]; p = 0.02; 43% versus 12%, respectively; odds ratio 5.6 [95% CI 1.6 to 20.3]; p = 0.005). We found no clinically important differences in postoperative patient-reported outcomes including Numeric Rating Scale and Oswestry Disability Index scores, and there were no differences in postoperative complications at 2 years of follow-up. CONCLUSION The ideal patient position during surgery for an ASD should decrease intra-abdominal pressure and induce lordosis as the abdomen hangs freely and hip flexion is decreased. The four-poster frame appears advantageous for long-segment fusions for spinal deformities. Future studies are needed to extend our analyses to different types of spinal deformities and validate radiologic and clinical outcomes with follow-up for more than 2 years. LEVEL OF EVIDENCE LEVEL III, therapeutic study.
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Affiliation(s)
- Hyung-Youl Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Sanggye Paik Hospital, College of Medicine, the Inje University, Seoul, Korea
| | - Sang-ll Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Soo-Bin Park
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
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Park HY, Kim YH, Ahn JH, Ha KY, Kim SI, Jung JW. Unstable Pathologic Vertebral Fractures in Multiple Myeloma : Propensity Score Matched Cohort Study between Reconstructive Surgery with Adjuvant Radiotherapy and Radiotherapy Alone. J Korean Neurosurg Soc 2022; 65:287-296. [PMID: 34979628 PMCID: PMC8918255 DOI: 10.3340/jkns.2021.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/12/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Although radiotherapy (RT) is recommended for multiple myeloma (MM) involving spine, the treatment of choice between reconstructive surgery with RT and RT alone for pathologic vertebral fractures (PVFs) associated with structural instability or neurologic compromises remains controversial. The purpose of this study was to evaluate the clinical efficacies of reconstructive surgery with adjuvant RT for treatment of MM with PVFs by comparing with matched cohorts treated with RT alone.
Methods Twenty-eight patients underwent reconstructive surgery followed by RT between 2008 and 2015 in a single institution, for management of PVFs associated with structural instability of the spine and/or neurologic compromises (group I). Twenty-eight patients were treated with RT alone (group II) after propensity score matching in a 1-to-1 format based on instability of the spine, as well as age and performance. Clinical outcomes including the overall survival rates, duration of independent ambulation, neurological status, and numeric rating scale (NRS) for back pain were compared.
Results Clinical and radiological features before treatment were similar in both groups. The median survival period was similar between the two groups. However, the mean duration of independent ambulation was significantly longer in group I (88.8 months; 95% confidence interval [CI], 66.0–111.5) than in group II (39.4 months; 95% CI, 25.2–53.6) (log rank test; p=0.022). Deterioration of Frankel grade (21.4% vs. 60.7%, p=0.024) and NRS for back pain (2.7±2.2 vs. 5.0±2.7, p=0.000) at the last follow-up were higher in the group II. Treatment-related complications were similar in both groups.
Conclusion In patients with unstable PVFs due to MM, reconstructive surgery may yield superior clinical outcomes compared with RT alone in maintaining independent ambulation and neurological status, as well as pain control despite similar median survival and complications.
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Affiliation(s)
- Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joo-Hyun Ahn
- Department of Orthopaedic Surgery, Mediplex Sejong Hospital, Incheon, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Woong Jung
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Chatani S, Haimoto S, Sato Y, Hasegawa T, Murata S, Yamaura H, Inaba Y. Preoperative Embolization of Spinal Metastatic Tumor: The Use of Selective Computed Tomography Angiography for the Detection of Radiculomedullary Arteries. Spine Surg Relat Res 2021; 5:284-291. [PMID: 34435153 PMCID: PMC8356237 DOI: 10.22603/ssrr.2020-0202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/14/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Preoperative embolization for metastatic spinal cord compression (MSCC) has a risk of spinal ischemia. This study aimed to assess the efficacy and safety of preoperative embolization in patients with MSCC and evaluate the use of computed tomography (CT) angiography for the detection of the radiculomedullary arteries (RMA). Methods This retrospective study included 20 patients (12 men and 8 women; median age, 66 years), who underwent preoperative embolization before a decompression surgery, which corresponded to 22 embolization procedures. The detection ability of RMA was evaluated using angiography and selective CT angiography. Surgical data including intraoperative blood loss and transfusion were also evaluated. Results Six RMAs were identified at the levels of affected vertebrae and one level above and below in the diagnostic spinal angiography. In addition to spinal angiography, adjunctive selective CT angiography allowed visualization of another five RMAs. Overall, 11 RMAs were identified in 9 patients. Preoperative embolization was successfully achieved in all patients. As regards complications related to embolization procedure, palsy exacerbated in one patient (4.5%), which improved postoperatively. During the surgical procedure, the mean intraoperative blood loss was 353.4±254.2 mL without intraoperative transfusion in all patients. Conclusions The present study showed small amounts of intraoperative blood loss without any severe complications related to preoperative embolization. Selective CT angiography was a useful technique to detect RMAs and contributed to the safety of preoperative embolization.
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Affiliation(s)
- Shohei Chatani
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shoichi Haimoto
- Department of Neurosurgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yozo Sato
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takaaki Hasegawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinichi Murata
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hidekazu Yamaura
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitaka Inaba
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
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11
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Facchini G, Parmeggiani A, Peta G, Martella C, Gasbarrini A, Evangelisti G, Miceli M, Rossi G. The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review. Eur Spine J 2021; 30:2839-2851. [PMID: 34415449 DOI: 10.1007/s00586-021-06963-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Claudia Martella
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Rossi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
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12
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Gao ZY, Zhang T, Zhang H, Pang CG, Xia Q. Effectiveness of Preoperative Embolization in Patients with Spinal Metastases: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e745-e757. [PMID: 34153484 DOI: 10.1016/j.wneu.2021.06.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/12/2021] [Accepted: 06/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Debate on the effectiveness of preoperative embolization for spinal metastatic lesions, especially for nonhypervascular tumors, has persisted. The present study aimed to identify the effectiveness of preoperative embolization in patients who had undergone surgery for spinal metastasis. METHODS Two of us (Z.T. and Z.H.) independently searched the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases to identify eligible clinical studies that had compared the outcomes of patients treated surgically for spinal metastatic disease with or without preoperative embolization. The primary outcomes included intraoperative blood loss, perioperative blood loss, and transfusion requirements. The secondary outcomes include the operative time, overall survival, and complication rates. Meta-analyses were performed for subgroups of hypervascular, nonhypervascular, and mixed tumors. A fixed effects model was applied when I2 was <50%, and a random effects model was applied when I2 was >50%. RESULTS A total of 12 studies (1 randomized controlled trial and 11 retrospective case-control studies), with 744 patients, were included. Significantly less intraoperative blood loss (mean difference [MD], -1171.49 mL; 95% confidence interval [CI], -2283.10 to -59.88; P = 0.039), fewer blood transfusions (MD, -3.13 U; 95% CI, -4.86 to -1.39; P < 0.001), and shorter operative times (MD, -33.91 minutes; 95% CI, -59.65 to -8.17; P = 0.010) were identified for the embolization group in the hypervascular subgroup. In the nonhypervascular and mixed tumor subgroups, no differences in effectiveness were identified in blood loss, transfusion requirement, or operative time when stratified by the use of embolization. The overall survival and complication rates were similar between the embolization and nonembolization groups in each subgroup. CONCLUSIONS The current data support the use of preoperative embolization for hypervascular metastatic tumors to the spine. However, little evidence is available to support the use of preoperative embolization for nonhypervascular metastatic tumors to the spine.
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Affiliation(s)
- Zhong-Yu Gao
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Tao Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Hui Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | | | - Qun Xia
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China.
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13
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Mohme M, Mende KC, Pantel T, Viezens L, Westphal M, Eicker SO, Dreimann M, Krätzig T, Stangenberg M. Intraoperative blood loss in oncological spine surgery. Neurosurg Focus 2021; 50:E14. [PMID: 34003622 DOI: 10.3171/2021.2.focus201117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative blood loss in patients undergoing oncological spine surgery poses a major challenge for vulnerable patients. The goal of this study was to assess how the surgical procedure, tumor type, and tumor anatomy, as well as anesthesiological parameters, affect intraoperative blood loss in oncological spine surgery and to use this information to generate a short preoperative checklist for spine surgeons and anesthesiologists to identify patients at risk for increased intraoperative blood loss. METHODS The authors performed a retrospective analysis of 430 oncological patients who underwent spine surgery between 2013 and 2018 at the university medical spine center. Enrolled patients had metastatic tumor of the spine requiring surgical decompression of neural structures and/or stabilization including tumor biopsy using an open, percutaneous, and/or combined dorsoventral approach. Patients requiring vertebro- and kyphoplasty or biopsy only were excluded. Statistical analyses performed included a multiple linear regression analysis. RESULTS The mean intraoperative blood loss in the study patient cohort was 1176 ± 1209 ml. In total, 33.8% of patients received intraoperative red blood cell transfusions. The statistical analyses showed that tumor histology indicating myeloma, operative procedure length, epidural spinal cord compression (ESCC) score, tumor localization, BMI, and surgical strategy were significantly associated with increased intraoperative blood loss or risk of needing allogeneic blood transfusions. Anesthesiological parameters such as the American Society of Anesthesiologists (ASA) Physical Status classification score were not associated with blood loss. Multiple linear regression analysis demonstrated good predictive value (r = 0.437) for a five-item preoperative checklist to identify patients at risk for high intraoperative blood loss. CONCLUSIONS The analyses performed in this study demonstrated key factors affecting intraoperative blood loss and showed that a simple preoperative checklist including these factors can be used to identify patients undergoing surgery for metastatic spine tumors who are at risk for increased intraoperative blood loss. ABBREVIATIONS ABT = allogeneic blood transfusion; ASA = American Society of Anesthesiologists; ESCC = epidural spinal cord compression; KW = Kruskal-Wallis; MET = metabolic equivalent of task; RBC = red blood cell.
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Affiliation(s)
| | | | | | - Lennart Viezens
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Marc Dreimann
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Martin Stangenberg
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Gong Y, Wang C, Liu H, Liu X, Jiang L. Only Tumors Angiographically Identified as Hypervascular Exhibit Lower Intraoperative Blood Loss Upon Selective Preoperative Embolization of Spinal Metastases: Systematic Review and Meta-Analysis. Front Oncol 2021; 10:597476. [PMID: 33585214 PMCID: PMC7874195 DOI: 10.3389/fonc.2020.597476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/02/2020] [Indexed: 01/25/2023] Open
Abstract
Background The role of preoperative embolization (PE) in reducing intraoperative blood loss (IBL) during surgical treatment of spinal metastases remains controversial. Methods A systematic search was conducted for retrospective studies and randomized controlled trials (RCTs) comparing the IBL between an embolization group (EG) and non-embolization group (NEG) for spinal metastases. IBL data of both groups were synthesized and analyzed for all tumor types, hypervascular tumor types, and non-hypervascular tumor types. Results In total, 839 patients in 11 studies (one RCT and 10 retrospective studies) were included in the analysis. For all tumor types, the average IBL did not differ significantly between the EG and NEG in the RCT (P = 0.270), and there was no significant difference between the two groups in the retrospective studies (P = 0.05, standardized mean difference [SMD] = −0.51, 95% confidence interval [CI]: −1.03 to 0.00). For hypervascular tumors determined as such by consensus (n = 542), there was no significant difference between the two groups (P = 0.52, SMD = −0.25, 95% CI: −1.01 to 0.52). For those determined as such using angiographic evidence, the IBL was significantly lower in the EG than in the NEG group, in the RCT (P = 0.041) and in the retrospective studies (P = 0.004, SMD = −0.93, 95% CI: −1.55 to −.30). For IBL of non-hypervascular tumor types, both the retrospective study (P = 0.215) and RCT (P = 0.947) demonstrated no statistically significant differences in IBL between the groups. Conclusions Only tumors angiographically identified as hypervascular exhibited lower IBL upon PE in this study. Further exploration of non-invasive methods to identify the vascularity of tumors is warranted.
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Affiliation(s)
- Yining Gong
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Health Science Center, Peking University, Beijing, China
| | - Changming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hua Liu
- Health Science Center, Peking University, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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15
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Premat K, Shotar E, Burns R, Shor N, Eloy G, Cormier É, Drir M, Morardet L, Lenck S, Sourour N, Chiras J, Dormont D, Bonaccorsi R, Clarençon F. Reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography in hypervascular spinal metastases prior embolization. Eur Radiol 2021; 31:4690-4699. [PMID: 33449182 DOI: 10.1007/s00330-020-07654-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization. METHODS All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized "yes vs no" scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics. RESULTS Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI [0.09-0.81]) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI [0.37-1.00]). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0). CONCLUSIONS TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool. KEY POINTS • TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases. • TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography. • TR-CE-MRA's spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.
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Affiliation(s)
- Kévin Premat
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France.
| | - Eimad Shotar
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Robert Burns
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Natalia Shor
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Gauthier Eloy
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Orthopaedic Surgery, F75013, Paris, France
| | - Évelyne Cormier
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Mehdi Drir
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Anaesthesiology, F75013, Paris, France
| | - Laetitia Morardet
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Oncology, F75013, Paris, France
| | - Stéphanie Lenck
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Nader Sourour
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Jacques Chiras
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Didier Dormont
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Raphaël Bonaccorsi
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Orthopaedic Surgery, F75013, Paris, France
| | - Frédéric Clarençon
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
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16
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Houten JK, Swiggett SJ, Hadid B, Choueka DM, Kinon MD, Buciuc R, Zumofen DW. Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury. World Neurosurg 2020; 143:374-388. [PMID: 32805465 DOI: 10.1016/j.wneu.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative embolization of spinal metastases may improve outcomes of resection by reducing surgical blood loss and operative time. Neurologic complications are rarely reported and the mechanisms leading to injury are poorly described. METHODS We present 2 illustrative cases of embolization-related neurologic injury from distinct mechanisms and the findings of a systemic literature review of similar complications according to the PRISMA guidelines. RESULTS A 77-year-old man with a history of renal cell carcinoma presented with gait dyscoordination and arm pain/weakness. Magnetic resonance imaging showed a C7/T1 mass causing severe compression of the C7/T1 roots and spinal cord. After embolization and tumor resection/fusion, lethargy prompted imaging showing multiple posterior circulation infarcts believed to be secondary to reflux of embolic particles. A 75-year-old man with renal cell carcinoma presented with L1 level metastasis causing conus compression and experienced paraplegia after superselective particle embolization presumed to be secondary to flow disruption of the artery of Adamkiewicz. Analysis of the literature yielded 6 articles reporting instances of cranial infarction/ischemia occurring in 10 patients, 12 articles reporting spinal cord ischemia/infarction occurring in 17 patients, and 5 articles reporting symptomatic postembolization tumoral swelling in 5 patients. CONCLUSIONS Neurologic injury is a risk of preoperative embolization of spinal metastasis from either compromise of spinal cord vascular supply or cranial stroke from reflux of embolic particles. Postprocedural tumor swelling rarely leads to clinical deficit. Awareness of these complications and the presumed mechanisms of injury may aid clinicians in implementing interventions and in counseling patients before treatment.
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Affiliation(s)
- John K Houten
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.
| | - Samuel J Swiggett
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Bana Hadid
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David M Choueka
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Merritt D Kinon
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Razvan Buciuc
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Daniel W Zumofen
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
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