Utility of the LACE index to assess risk of mortality and readmission in patients with spinal infections

Retrospective cohort study. To assess the utility of the LACE index for predicting death and readmission in patients with spinal infections (SI). SIs are severe conditions, and their incidence has increased in recent years. The LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) index quantifies the risk of mortality or unplanned readmission. It has not yet been validated for SIs. LACE indices were calculated for all adult patients who underwent surgery for spinal infection between 2012 and 2021. Data were collected from a single academic teaching hospital. Outcome measures included the LACE index, mortality, and readmission rate within 30 and 90 days. In total, 164 patients were analyzed. Mean age was 64.6 (± 15.1) years, 73 (45%) were female. Ten (6.1%) patients died within 30 days and 16 (9.8%) died within 90 days after discharge. Mean LACE indices were 13.4 (± 3.6) and 13.8 (± 3.0) for the deceased patients, compared to 11.0 (± 2.8) and 10.8 (± 2.8) for surviving patients (p = 0.01, p < 0.001), respectively. Thirty-seven (22.6%) patients were readmitted ≤ 30 days and 48 (29.3%) were readmitted ≤ 90 days. Readmitted patients had a significantly higher mean LACE index compared to non-readmitted patients (12.9 ± 2.1 vs. 10.6 ± 2.9, < 0.001 and 12.8 ± 2.3 vs. 10.4 ± 2.8, p < 0.001, respectively). ROC analysis for either death or readmission within 30 days estimated a cut-off LACE index of 12.0 points (area under the curve [AUC] 95% CI, 0.757 [0.681-0.833]) with a sensitivity of 70% and specificity of 69%. Patients with SI had high LACE indices that were associated with high mortality and readmission rates. The LACE index can be applied to this patient population to predict the risk of early death or unplanned readmission.

[Low Back Pain - When Is Surgical Therapy Promising?]

Low Back Pain - When Is Surgical Therapy Promising? Abstract. Low back pain is the number one widespread disease and leads to a high socioeconomic burden. In most cases, low back pain has a non-specific cause, which can be treated conservatively. For low back pain with specific pathoanatomical causes, surgery is usually only indicated for cases refractory to conservative measures or for patients presenting with neurological deficits or mechanical instability. Especially in patients with herniated discs, spinal canal stenosis and spondylolisthesis, surgical treatment has been shown to lead to good or very good long-term patient outcomes. However, careful patient selection and education are critical for successful postoperative patient outcome.

P18.10.B Natural history of meningiomas - a serial volumetric analysis of 240 tumors

Background

The management of asymptomatic intracranial meningiomas is controversial. Through the assessment of growth predictors, we aimed to create the basis for practicable clinical pathways for the management of these tumors.

Material and Methods

We volumetrically analyzed meningiomas radiologically diagnosed at our institution between 2003 and 2015. For this purpose, we used exclusively thin-layered MR images (i.e. ≤ 2mm slice thickness). The primary endpoint was tumor growth defined as a 14.35% increase in tumor volume. We identified predictive clinical and radiological characteristics and used the significant variables from a multivariable regression model to construct a decision tree based on the exhaustive Chi-squared Automatic Interaction Detection (exhaustive CHAID) algorithm.

Results

Of 240 meningiomas, 159 (66.3%) demonstrated growth during a mean observation period of 46.9 months. On multivariable logistic regression analysis, older age (OR=0.979 (0.958-1.000), p=0.048) and presence of calcification (OR=0.442 (0.224-0.872), p=0.019) had a negative predictive value for tumor growth, while T2-signal iso-/hyperintensity (OR=4.415 (2.056-9.479), p&lt;0.001) had a positive predictive value. A decision tree model yielded three growth risk groups based on T2-signal intensity and presence of calcifications with a proportion of growing tumors of 34.1% in the low risk group, 60.0% in the intermediate risk group and 80.2% in the high risk group. Median tumor volume doubling time (Td) was 185.7 months in the low risk, 100.1 months in the intermediate risk and 51.7 months in the high risk group (p&lt;0.001). While 0% of meningiomas in the low and intermediate risk group had a Td of ≤12 months, 8.9% in the high risk group did so (p=0.021).

Conclusion

Most meningiomas demonstrated growth during follow-up. The presence or absence of calcifications and the signal intensity on T2-weighted imaging allow a practical and simple stratification of meningiomas into low, intermediate and high risk tumors. Small tumors in the low or intermediate risk categories can be monitored with longer follow-up intervals, whereas in the high risk category proactive management decisions can be justified.

A standardized model for in vitro testing of sutures and patches for watertight dural closure

OBJECTIVE

CSF leaks are common complications of spinal and cranial surgeries. Several dural grafts and suture techniques are available to achieve watertight dural closure, but the effectiveness of these techniques remains unclear. The authors developed a standardized in vitro model to test available grafts and suture techniques alone or in combination to find the technique with the most watertight dural closure.

METHODS

A fluid chamber with a dural fixation device, infusion pump, pressure gauge, and porcine pericardium as a dural equivalent was assembled to provide the reusable device for testing. The authors performed dural closure in 4 different fashions, as follows: A) using running versus simple interrupted suture technique and different suture materials to close a 3-cm incision; B) selecting commonly used sealants and dural patches in combination with a running suture; C) performing duraplasty (1.5 × 1.5-cm square defect) with different dural substitutes in a stand-alone fashion; and D) performing duraplasty with different dural substitutes in a double-layer fashion. Each technique was tested 6 times. The hydrostatic burst pressure (BP) was measured and compared using the Kruskal-Wallis test or the Mann-Whitney U-test. Values are reported as mean ± SD.

RESULTS

There was no significant difference between the running and simple interrupted suture technique (p = 0.79). Adding a patch or sealant to a suture resulted in a 1.7- to 14-fold higher BP compared to solitary suture closure (36.2 ± 24.27 cm H2O and 4.58 ± 1.41 cm H2O, respectively; p < 0.001). The highest BP was achieved by adding DuraSeal or TachoSil (82.33 ± 12.72 cm H2O and 74.17 ± 12.64 cm H2O, respectively). For closing a square defect, using a double-layer duraplasty significantly increased BP by a factor of 4-12 compared to a single-layer duraplasty (31.71 ± 12.62 cm H2O vs 4.19 ± 0.88 cm H2O, respectively; p < 0.001). The highest BP was achieved with the combination of Lyomesh and TachoSil (43.67 ± 11.45 cm H2O).

CONCLUSIONS

A standardized in vitro model helps to objectify the watertightness of dural closure. It allows testing of sutures and dural grafts alone or in combination. In the authors' testing, a running 6-0 monofilament polypropylene suture combined with DuraSeal or TachoSil was the technique achieving the highest BP. For the duraplasty of square defects, the double-layer technique showed the highest efficacy.

Safety and efficacy of stand-alone anterior lumbar interbody fusion in low-grade L5-S1 isthmic spondylolisthesis

Introduction

Surgical management of isthmic spondylolisthesis is controversial and reports on anterior approaches in the literature are scarce.

Research question

To evaluate the safety and efficacy of stand-alone anterior lumbar interbody fusion (ALIF) in patients with symptomatic low-grade L5-S1 isthmic spondylolisthesis.

Material and methods

All adult patients with isthmic spondylolisthesis of the lumbosacral junction treated in a single institution between 2008 and 2019 with stand-alone ALIF were screened. A titan cage was inserted at L5-S1 with vertebral anchoring screws. Prospectively collected surgical, clinical and radiographic data were analyzed retrospectively.

Results

34 patients (19 men, 15 women, mean age 52.5 ​± ​11.5 years) with a mean follow-up of 3.2 (±2.5) years were analyzed. 91.2% (n ​= ​31) of patients had a low-grade spondylolisthesis and 8.8% (n ​= ​3) grade III according to Meyerding classification. Mean COMI and ODI scores improved significantly from 6.9 (±1.5) and 35.5 (±13.0) to 2.0 (±2.5) and 10.2 (±13.0), respectively after one year, and to 1.7 (±2.5) and 8.2 (±9.6), respectively, after two years. The COMI and ODI scores improved in 86.4% and 80%, respectively, after one year and 92.9% of patients after two years by at least the minimal clinically important difference. No intraoperative complications were recorded. 8.8% (n ​= ​3) of patients needed a reoperation.

Discussion and conclusion

After stand-alone ALIF for symptomatic isthmic spondylolisthesis, the patients improved clinically important after one and two years. Stand-alone ALIF is a safe and effective surgical treatment option for low-grade isthmic spondylolisthesis.

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Report of a series of patients with symptomatic low-grade L5-S1 isthmic spondylolisthesis treated by stand-alone ALIF.

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Patient reported outcomes showed clinically important improvements after one and two years.

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Stand-alone ALIF proved to be a safe and effective technique to treat symptomatic low-grade L5-S1 isthmic spondylolisthesis.

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There were no vascular or other major complications.

Negligible Systemic Uptake of Suprafascial Vancomycin Powder Following Instrumented Posterior Spinal Fusion-Preliminary Results From A Randomized Clinical Trial (VANCO Trial)

BACKGROUND

Intrawound vancomycin powder is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery. However, there are concerns relating to its safety profile and toxicity. Data on systemic uptake of suprafascially administered vancomycin powder following instrumented spinal fusion is lacking.

OBJECTIVE

To study the systemic uptake and safety of suprafascially administered vancomycin powder in the early postoperative phase following open instrumented posterior spinal fusion.

METHODS

This was a substudy of an ongoing randomized clinical trial. Eligible adult patients were randomized 1:1 to either receive suprafascial vancomycin powder before wound closure or not to receive vancomycin powder. Serum vancomycin levels were assessed on postoperative days 1 and 2, serum creatinine levels were measured pre- and post-operatively. Adverse events up to 6 wk following surgery were recorded.

RESULTS

Among 34 randomized patients (mean age 62 yr, range 31-84 yr; 18 [53%] women), 17 received vancomycin powder. No detectable serum vancomycin levels (>4.0 mg/L) were found. Proportion of adverse events per patient in the vancomycin and control group, respectively, were 29.4% (5/17) vs 11.8% (2/17) (OR 3.12; 95% CI, 0.52; 19.38; P = .398). No patient had nephrotoxicity or ototoxicity in either group.

CONCLUSION

Suprafascial vancomycin powder in open instrumented spinal fusion surgery is safe and results in negligible systemic uptake. Final results of the VANCO Trial need to be awaited for conclusive data on the efficacy of vancomycin for SSI prevention and its impact on wound healing.

The surgical challenge of ossified ventrolateral spinal meningiomas: tricks and pearls for managing large ossified meningiomas of the thoracic spine

The authors present an illustrative technical note on microsurgical resection of ventrolateral completely ossified spinal meningiomas (OSMs) and a literature review of the surgical management of calcified spinal meningiomas or OSMs. These tumors are surgically demanding due to their solid consistency, especially when in a ventrolateral location with dislocation of the spinal cord. A challenging case with significant thoracic cord compression and displacement is described. Due to the firm consistency and the ventrolateral localization of the meningioma, a piecemeal resection was necessary. This could have resulted in a free-floating tumor remnant adherent to the spinal cord, impeding safe tumor resection. To avoid such a remnant, an anchoring burr hole was drilled at the border between the spinal cord and the adamantine tumor mass. Then, a microdissector was placed within the anchoring burr hole and the tumor was gently pulled laterally while drilling away the medial parts of the ossified tumor. This procedure was repeated until separation of the tumor from the spinal cord was possible and a gross-total resection (Simpson grade II) was manageable. Throughout the procedure, continuous intraoperative neurophysiological monitoring was performed.

ALS-Associated Endoplasmic Reticulum Proteins in Denervated Skeletal Muscle: Implications for Motor Neuron Disease Pathology

Alpha-motoneurons and muscle fibres are structurally and functionally interdependent. Both cell types particularly rely on endoplasmic reticulum (ER/SR) functions. Mutations of the ER proteins VAPB, SigR1 and HSP27 lead to hereditary motor neuron diseases (MNDs). Here, we determined the expression profile and localization of these ER proteins/chaperons by immunohistochemistry and immunoblotting in biopsy and autopsy muscle tissue of patients with amyotrophic lateral sclerosis (ALS) and other neurogenic muscular atrophies (NMAs) and compared these patterns to mouse models of neurogenic muscular atrophy. Postsynaptic neuromuscular junction staining for VAPB was intense in normal human and mouse muscle and decreased in denervated Nmd^2J mouse muscle fibres. In contrast, VAPB levels together with other chaperones and autophagy markers were increased in extrasynaptic regions of denervated muscle fibres of patients with MNDs and other NMAs, especially at sites of focal myofibrillar disintegration (targets). These findings did not differ between NMAs due to ALS and other causes. G93A-SOD1 mouse muscle fibres showed a similar pattern of protein level increases in denervated muscle fibres. In addition, they showed globular VAPB-immunoreactive structures together with misfolded SOD1 protein accumulations, suggesting a primary myopathic change. Our findings indicate that altered expression and localization of these ER proteins and autophagy markers are part of the dynamic response of muscle fibres to denervation. The ER is particularly prominent and vulnerable in both muscle fibres and alpha-motoneurons. Thus, ER pathology could contribute to the selective build-up of degenerative changes in the neuromuscular axis in MNDs.

Loss of function of the ALS protein SigR1 leads to ER pathology associated with defective autophagy and lipid raft disturbances

Intracellular accumulations of altered, misfolded proteins in neuronal and other cells are pathological hallmarks shared by many neurodegenerative diseases including amyotrophic lateral sclerosis (ALS). Mutations in several genes give rise to familial forms of ALS. Mutations in Sigma receptor 1 have been found to cause a juvenile form of ALS and frontotemporal lobar degeneration (FTLD). We recently described altered localization, abnormal modification and loss of function of SigR1 in sporadic ALS. In order to further elucidate the molecular mechanisms underlying SigR1-mediated alterations in sporadic and familial ALS, we extended our previous studies using neuronal SigR1 knockdown cell lines. We found that loss of SigR1 leads to abnormal ER morphology, mitochondrial abnormalities and impaired autophagic degradation. Consistent with these results, we found that endosomal trafficking of EGFR is impaired upon SigR1 knockdown. Furthermore, in SigR1-deficient cells the transport of vesicular stomatitis virus glycoprotein is inhibited, leading to the accumulation of this cargo protein in the Golgi apparatus. Moreover, depletion of SigR1 destabilized lipid rafts and associated calcium mobilization, confirming the crucial role of SigR1 in lipid raft and intracellular calcium homeostasis. Taken together, our results support the notion that loss of SigR1 function contributes to ALS pathology by causing abnormal ER morphology, lipid raft destabilization and defective endolysosomal pathways.