The importance of sagittal spinal balance and lumbopelvic parameters is now well understood. The popularization of various osteotomies, including Smith-Peterson, Ponte, and pedicle subtraction osteotomies (PSOs), as well as vertebral column resections, have greatly enhanced the spine surgeon’s ability to recognize and effectively treat sagittal imbalance. Yet rare circumstances remain, most notably in distal kyphotic deformities and patients with extremely elevated pelvic incidences, where these techniques remain inadequate. In this article, the authors describe a patient with severe sagittal imbalance despite multiple prior anterior and posterior reconstructive surgeries in which a sacral PSO was performed with good results. A description of this technique as well as a brief review of the literature is provided.
Ali K. Ozturk, Patricia Zadnik Sullivan and Vincent Arlet
Patricia Zadnik Sullivan, Ahmed Albayar, Ashwin G. Ramayya, Brendan McShane, Paul Marcotte, Neil R. Malhotra, Zarina S. Ali, H. Isaac Chen, M. Burhan Janjua, Comron Saifi, James Schuster, M. Sean Grady, Joshua Jones and Ali K. Ozturk
Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes.
In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N − 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model.
Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy.
At the authors’ institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.