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Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance

Gaston Tabourel, Louis-Marie Terrier, Arnaud Dubory, Joseph Cristini, Louis-Romée Le Nail, Ann-Rose Cook, Kévin Buffenoir, Hugues Pascal-Moussellard, Alexandre Carpentier, Bertrand Mathon, and Aymeric Amelot

OBJECTIVE

Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM.

METHODS

It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017.

RESULTS

In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita’s prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35–0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64–0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54–0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen’s kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen’s kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a “slight” rate of agreement (weighted Cohen’s kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival.

CONCLUSIONS

The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.

In Journal of Neurosurgery: Spine Publish Before Print

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Boomer Sooner: neurosurgery at the University of Oklahoma

Panayiotis E. Pelargos, Camille K. Milton, Michael D. Martin, Donald D. Horton, Stanley Pelofsky, Mary K. Gumerlock, Timothy B. Mapstone, and Ian F. Dunn

Neurosurgery at the University of Oklahoma has played a pivotal role in the development of the specialty in the state. Its history spans nearly 90 years, beginning in 1931 when Dr. Harry Wilkins established the first neurosurgical practice in the state at the University of Oklahoma. Together with his first trainee, Dr. Jess Herrmann, Wilkins established the Division of Neurosurgery and its training program in 1946. Through their tireless work, the division and its residency program gained renown for its patient care and teaching, and this tradition was carried forward by its subsequent leaders. The Department of Neurosurgery was established in 1993. From humble beginnings, neurosurgery at the University of Oklahoma has grown a comprehensive residency program with an intensive curriculum, leveraging the clinical and academic breadth afforded by relationships with the College of Medicine, the University of Oklahoma Health Sciences Center, and allied clinical and research partners. Here, the authors recount the history of neurosurgery at the University of Oklahoma, the flagship academic neurosurgical program in the state.

In Journal of Neurosurgery Publish Before Print

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Cellular transplantation for Parkinson’s disease: a strategy whose time has passed

Ron L. Alterman

In Journal of Neurosurgery Publish Before Print

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Comparison of transorbital ultrasound measurements to predict intracranial pressure in brain-injured patients requiring external ventricular drainage

Jin Young Youm, Jae Hoon Lee, and Hyun Seok Park

OBJECTIVE

The optic nerve sheath diameter (ONSD) excluding the dura mater (ONSDE; i.e., the subarachnoid diameter) and the ONSD including the dura mater (ONSDI) have been used differently in studies, but the predictive ability of these two different measurements of the ONSD as measured by invasive intracranial pressure (ICP) monitoring has never been compared. Additionally, studies on the prediction of ICP using central retinal artery (CRA) Doppler ultrasonography are scarce. The authors aimed to determine how the two different ONSD measurements, the ONSD/eyeball transverse diameter (ETD) ratio, and transorbital Doppler ultrasonography parameters are associated with ICP via external ventricular drainage (EVD).

METHODS

This prospective observational study included 50 patients with brain injury who underwent EVD between August 2019 and September 2020. The mean of three repeated measurements of the ONSDI and ONSDE was calculated to reduce artifact and off-axis measurements. ETD, an immutable value, was measured from the initial brain CT with a clear outline of the eyeball. Simultaneously, flow velocities in the CRA and posterior ciliary artery (PCA) were compared with the ICP.

RESULTS

The ONSDE, ONSDI, and ONSD/ETD ratio were significantly associated with ICP (p = 0.005, p < 0.001, and p < 0.001, respectively). The ONSD/ETD ratio showed the highest predictive power of increased ICP (area under the curve [AUC] 0.897). The ONSDI was correlated more with the ICP than was the ONSDE (AUC 0.855 vs 0.783). None of the Doppler ultrasonography parameters in the CRA and PCA were associated with ICP.

CONCLUSIONS

The ONSD/ETD ratio is a better predictor of increased ICP compared with the ONSDI or ONSDE in brain-injured patients with nonsevere ICP. The ONSDI may be more available for predicting the ICP than the ONSDE.

In Journal of Neurosurgery Publish Before Print

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Correlation of anatomical involvement patterns of insular gliomas with subnetworks of the limbic system

Ege Ülgen, Fuat Kaan Aras, Erdal Coşgun, Ayça Erşen-Danyeli, Alp Dinçer, M. İmre Usseli, Koray Özduman, and M. Necmettin Pamir

OBJECTIVE

Gliomas frequently involve the insula both primarily and secondarily by invasion. Despite the high connectivity of the human insula, gliomas do not spread randomly to or from the insula but follow stereotypical anatomical involvement patterns. In the majority of cases, these patterns correspond to the intrinsic connectivity of the limbic system, except for tumors with aggressive biology. On the basis of these observations, the authors hypothesized that these different involvement patterns may be correlated with distinct outcomes and analyzed these correlations in an institutional cohort.

METHODS

Fifty-nine patients who had undergone surgery for insular diffuse gliomas and had complete demographic, pre- and postoperative imaging, pathology, molecular genetics, and clinical follow-up data were included in the analysis (median age 37 years, range 21–71 years, M/F ratio 1.68). Patients with gliomatosis and those with only minor involvement of the insula were excluded. The presence of T2-hyperintense tumor infiltration was evaluated in 12 anatomical structures. Hierarchical biclustering was used to identify co-involved structures, and the findings were correlated with established functional anatomy knowledge. Overall survival was evaluated using Kaplan-Meier and Cox proportional hazards regression analysis (17 parameters).

RESULTS

The tumors involved the anterior insula (98.3%), posterior insula (67.8%), temporal operculum (47.5%), amygdala (42.4%), frontal operculum (40.7%), temporal pole (39%), parolfactory area (35.6%), hypothalamus (23.7%), hippocampus (16.9%), thalamus (6.8%), striatum (5.1%), and cingulate gyrus (3.4%). A mean 4.2 ± 2.6 structures were involved. On the basis of hierarchical biclustering, 7 involvement patterns were identified and correlated with cortical functional anatomy (pure insular [11.9%], olfactocentric [15.3%], olfactoopercular [33.9%], operculoinsular [15.3%], striatoinsular [3.4%], translimbic [11.9%], and multifocal [8.5%] patterns). Cox regression identified hippocampal involvement (p = 0.006) and postoperative tumor volume (p = 0.027) as significant negative independent prognosticators of overall survival and extent of resection (p = 0.015) as a significant positive independent prognosticator.

CONCLUSIONS

The study findings indicate that insular gliomas primarily involve the olfactocentric limbic girdle and that involvement in the hippocampocentric limbic girdle is associated with a worse prognosis.

In Journal of Neurosurgery Publish Before Print

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Effect of segmental lordosis on early-onset adjacent-segment disease after posterior lumbar interbody fusion

Shinya Okuda, Yukitaka Nagamoto, Shota Takenaka, Masato Ikuta, Tomiya Matsumoto, Yoshifumi Takahashi, Masayuki Furuya, and Motoki Iwasaki

OBJECTIVE

Although several reports have described adjacent-segment disease (ASD) after posterior lumbar interbody fusion (PLIF), there have been only a few reports focusing on early-onset ASD occurring within 3 years after primary PLIF. The purpose of this study was to investigate the prevalence and postoperative pathologies of early-onset ASD and its relation with radiological parameters such as segmental lordosis (SL).

METHODS

The authors reviewed a total of 256 patients who underwent single-segment PLIF at L4–5 for degenerative lumbar spondylolisthesis (DLS) and were followed up for at least 5 years. The definition of ASD was a symptomatic condition requiring an additional operation at the adjacent fusion segment in patients who had undergone PLIF. ASD occurring within 3 years after primary PLIF was categorized as early-onset ASD. As a control group, 54 age- and sex-matched patients who had not suffered from ASD for more than 10 years were selected from this series.

RESULTS

There were 42 patients with ASD at the final follow-up. ASD prevalence rates at 3, 5, and 10 years postoperatively and at the final follow-up were 5.0%, 8.2%, 14.1%, and 16.4%, respectively. With respect to ASD pathologies, lumbar disc herniation (LDH) was significantly more common in early-onset ASD, while lumbar spinal stenosis and DLS occurred more frequently in late-onset ASD. Significant differences were detected in the overall postoperative range of motion (ROM) and in the changes in ROM (ΔROM) at L3–4 (the cranial adjacent fusion segment) and changes in SL (ΔSL) at L4–5 (the fused segment), while there were no significant differences in other pre- and postoperative parameters. In stepwise logistic regression analysis, ΔSL was identified as an independent variable (p = 0.008) that demonstrated significant differences, especially in early-onset ASD (control 1.1° vs overall ASD −2.4°, p = 0.002; control 1.1° vs early-onset ASD −6.6°, p = 0.00004).

CONCLUSIONS

The study results indicated that LDH was significantly more common as a pathology in early-onset ASD and that ΔSL was a major risk factor for ASD, especially early-onset ASD.

In Journal of Neurosurgery: Spine Publish Before Print

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Guidelines for optimal utilization of social media for brain tumor stakeholders

Nima Hamidi, Brij Karmur, Stephanie Sperrazza, Julia Alexieva, Liz Salmi, Brad E. Zacharia, Edjah K. Nduom, Aaron A. Cohen-Gadol, James T. Rutka, and Alireza Mansouri

OBJECTIVE

Effective use of social media (SM) by medical professionals is vital for better connections with patients and dissemination of evidence-based information. A study of SM utilization by different stakeholders in the brain tumor community may help determine guidelines for optimal use.

METHODS

Facebook, Twitter, and YouTube were searched by using the term “Brain Tumor.” Platform-specific metrics were determined, including audience size, as a measure of popularity, and mean annual increase in audience size, as a measure of performance on SM. Accounts were categorized on the basis of apparent ownership and content, with as many as two qualitative themes assigned to each account. Correlations of content themes and posting behavior with popularity and performance metrics were assessed by using the Pearson’s test.

RESULTS

Facebook (67 pages and 304,581 likes) was predominantly used by organizations (64% of pages). Top themes on Facebook, Twitter, and YouTube were charity and fundraising (67% of pages), education and research (72% of accounts), and experience sharing and support seeking (48% of videos, 60% of views, and 82% of user engagement), respectively. On Facebook, only the presence of other concurrent platforms influenced a page’s performance (rho = 0.59) and popularity (rho = 0.61) (p < 0.05). On Twitter, the number of monthly tweets (rho = 0.66) and media utilization (rho = 0.78) were significantly correlated with increased popularity and performance (both p < 0.05). Personal YouTube videos (30% of videos and 61% of views) with the theme of experience sharing and support seeking had the highest level of engagement (60% of views, 70% of comments, and 87% of likes).

CONCLUSIONS

Popularity and prevalence of qualitative themes differ among SM platforms. Thus, optimal audience engagement on each platform can be achieved with thematic considerations. Such considerations, along with optimal SM behavior such as media utilization and multiplatform presence, may help increase content popularity and thus increase community access to neurooncology content provided by medical professionals.

In Journal of Neurosurgery Publish Before Print

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Impact of focal apex angle on postoperative decompression status of the spinal cord and neurological recovery after cervical laminoplasty

Shinya Kato, Hisanori Mihara, Takanori Niimura, Kenichi Watanabe, Takuya Kawai, Hyonmin Choe, and Yutaka Inaba

OBJECTIVE

Although anterior compression factors and cervical alignment affect neural decompression, cervical laminoplasty may be used to achieve indirect posterior decompression. The focal apex (FA) angle of the anterior compression factor of the spine represents the degree of anterior prominence toward the spinal cord. The authors investigated the mechanism underlying the influence of FA angle and cervical alignment on spinal cord alignment (SCA) after laminoplasty, including how high-intensity signal cord change (HISCC) on preoperative T2-weighted MRI (T2-MRI) may affect neurological improvement.

METHODS

We performed a retrospective study of patients who underwent laminoplasty for CSM or OPLL at two hospitals (Kanto Rosai Hospital, Kawasaki City, and Yokohama Minami Kyousai Hospital, Yokohama City, Japan) between April 2004 and March 2015. In total, 109 patients (mean age 67.3 years) with cervical compression myelopathy were included. FA angle was defined as the preoperative angle between the lines from the top of the prominence to the upper and lower adjacent vertebrae. Preoperative cervical alignment was measured between the C2 and C7 vertebrae (C2–7 angle). MRI was used to classify SCA as lordosis (type-L SCA), straight (type-S), local kyphosis (type-LK), or kyphosis (type-K). Preoperative HISCC was investigated by using T2-MRI. Neurological status was evaluated by using the Japanese Orthopaedic Association score.

RESULTS

The mean preoperative FA and C2–7 angles were 32.1° and 12.4°, respectively. Preoperative SCA was type-L or type-S in 53 patients. The neurological recovery rate (NRR) was significantly higher for patients with preoperative type-L and type-S SCA (51.4% for those with type-L and 45.0% for those with type-S) than for patients with other types (35.3% for those with type-LK and 31.7% for those with type-K). Among patients with preoperative type-L or type-S SCA, 87.3% maintained SCA; however, 5/12 (41.7%) patients with a preoperative average C2–7 angle < 12.4° and an average FA angle > 32.1° had postoperative type-LK or type-K SCA. SCA changed to type-L or type-S in 13.0% of patients with preoperative type-LK or type-K SCA. Moreover, in these patients, FA angle was significantly smaller and NRR was significantly higher than in other patients in whom postoperative SCA remained type-LK or type-K. Preoperative T2-MRI showed 73 patients with HISCC (43 with type-L and type-S, and 30 with type-LK and type-K SCA) and 36 without HISCC (20 with type-L and type-S, and 16 with type-LK and type-K SCA); the NRRs of these patients were 42.6% and 41.2%, respectively. No significant differences in SCA or NRR were observed between patients with and without HISCC.

CONCLUSIONS

NRR depends on preoperative SCA type; however, it is possible to change the type of SCA after laminoplasty. Preoperative FA and C2–7 angles influence change in SCA; therefore, they are important parameters for successful decompression with cervical laminoplasty.

In Journal of Neurosurgery: Spine Publish Before Print

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Impact of international research fellows in neurosurgery: results from a single academic center

Wuyang Yang, Jordina Rincon-Torroella, James Feghali, Adham M. Khalafallah, Wataru Ishida, Alexander Perdomo-Pantoja, Alfredo Quiñones-Hinojosa, Michael Lim, Gary L. Gallia, Gregory J. Riggins, William S. Anderson, Sheng-Fu Larry Lo, Daniele Rigamonti, Rafael J. Tamargo, Timothy F. Witham, Ali Bydon, Alan R. Cohen, George I. Jallo, Alban Latremoliere, Mark G. Luciano, Debraj Mukherjee, Alessandro Olivi, Lintao Qu, Ziya L. Gokaslan, Daniel M. Sciubba, Betty Tyler, Henry Brem, and Judy Huang

OBJECTIVE

International research fellows have been historically involved in academic neurosurgery in the United States (US). To date, the contribution of international research fellows has been underreported. Herein, the authors aimed to quantify the academic output of international research fellows in the Department of Neurosurgery at The Johns Hopkins University School of Medicine.

METHODS

Research fellows with Doctor of Medicine (MD), Doctor of Philosophy (PhD), or MD/PhD degrees from a non-US institution who worked in the Hopkins Department of Neurosurgery for at least 6 months over the past decade (2010–2020) were included in this study. Publications produced during fellowship, number of citations, and journal impact factors (IFs) were analyzed using ANOVA. A survey was sent to collect information on personal background, demographics, and academic activities.

RESULTS

Sixty-four international research fellows were included, with 42 (65.6%) having MD degrees, 17 (26.6%) having PhD degrees, and 5 (7.8%) having MD/PhD degrees. During an average 27.9 months of fellowship, 460 publications were produced in 136 unique journals, with 8628 citations and a cumulative journal IF of 1665.73. There was no significant difference in total number of publications, first-author publications, and total citations per person among the different degree holders. Persons holding MD/PhDs had a higher number of citations per publication per person (p = 0.027), whereas those with MDs had higher total IFs per person (p = 0.048). Among the 43 (67.2%) survey responders, 34 (79.1%) had nonimmigrant visas at the start of the fellowship, 16 (37.2%) were self-paid or funded by their country of origin, and 35 (81.4%) had mentored at least one US medical student, nonmedical graduate student, or undergraduate student.

CONCLUSIONS

International research fellows at the authors’ institution have contributed significantly to academic neurosurgery. Although they have faced major challenges like maintaining nonimmigrant visas, negotiating cultural/language differences, and managing self-sustainability, their scientific productivity has been substantial. Additionally, the majority of fellows have provided reciprocal mentorship to US students.

In Journal of Neurosurgery Publish Before Print

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Importance of achieving Scoliosis Research Society–22r minimal clinically important difference for improving patient satisfaction after adult spinal deformity surgery

Hideyuki Arima, Tomohiko Hasegawa, Yu Yamato, Go Yoshida, Tomohiro Banno, Shin Oe, Yuki Mihara, Hiroki Ushirozako, Tomohiro Yamada, Yuh Watanabe, Koichiro Ide, Keiichi Nakai, Kenta Kurosu, and Yukihiro Matsuyama

OBJECTIVE

Achievement of minimal clinically important differences (MCIDs) in the Scoliosis Research Society–22r (SRS-22r) subdomains represents surgical efficacy. However, whether achievements of MCIDs in SRS-22r domains are associated with long-term satisfaction in patients with adult spinal deformity (ASD) is unclear. This study aimed to elucidate factors affecting patient satisfaction after thoracopelvic corrective fusion surgery in patients with ASD.

METHODS

Data obtained in 187 patients with ASD who underwent extensive corrective fusion surgery from the thoracic spine to the pelvis between 2010 and 2017 and underwent follow-up for 2 years were retrospectively reviewed. The authors investigated the likelihood of achieving MCIDs in the function, pain, self-image, mental health, and subtotal domains 2 years after surgery. The following MCID values were used: function, 0.90; pain, 0.85; self-image, 1.05; mental health, 0.70; and subtotal, 1.05. Multivariate analysis was performed to evaluate factors associated with patient satisfaction 2 years after surgery.

RESULTS

The average satisfaction scores in the group that achieved MCID and the group that did not were as follows: 3.97 and 3.37 for function (p < 0.001), 3.66 and 3.51 for pain (p = 0.221), 3.84 and 3.06 for self-image (p < 0.001), 3.82 and 3.28 for mental health (p < 0.001), and 3.96 and 3.30 for subtotal (p < 0.001), respectively. Except for the pain domain, the group that achieved MCIDs showed greater satisfaction than the group that did not achieve MCIDs. On multivariate analysis, factors related to postoperative satisfaction were achievement of SRS-22r self-image (standardization coefficient 0.322, p < 0.001) and function (standardization coefficient 0.179, p = 0.026) MCIDs. Perioperative complications and revision surgery were not related to patient satisfaction.

CONCLUSIONS

Multivariate analysis demonstrated that achievement of MCIDs in SRS-22r self-image and function domains was significantly associated with postoperative satisfaction. Given that patients with poor preoperative health-related quality of life are more likely to achieve MCIDs in SRS-22r domains, surgeons should carefully consider whether to operate on patients with relatively good baseline health-related quality of life when making surgical decisions.

In Journal of Neurosurgery: Spine Publish Before Print