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Danica R. Kindrachuk and Daryl R. Fourney

Object

The Saskatchewan Spine Pathway (SSP) was introduced to improve quality and access to care for patients with low-back and leg pain in the province. There is very limited data regarding the efficacy of nonsurgeon triage of surgical referrals. The objective of this early implementation study was to determine how the SSP affects utilization of MRI and spine surgery.

Methods

The authors performed a retrospective analysis of 87 consecutive patients with low-back and leg pain who were initially referred to a spine surgeon but were instead redirected to the SSP clinic between May 1, 2011, and November 30, 2011. The SSP clinic triaged patients into 2 groups: Group A (nonsurgical management) and Group B (referred back to the spine surgeon). The SSP classification was modified from the classification proposed by Hall et al. Pain and disability were scored by pain-related visual analog scale, modified Oswestry Disability Index, and EuroQol-5D.

Results

Sixty-two patients (Group A, 71.3%) were discharged after patient education, self-care advice, and/or referral for additional mechanical therapies. Although only 25 patients (Group B, 28.7%) were directed back to the surgeon, the final percentage (12.6%) offered surgery was similar to that of historic controls (15%). Total MRI utilization was significantly lower in Group A (25.8%) than Group B (92.0%) (p < 0.0001). Nonsurgeon triage captured all red flags detected by the surgeon. Patients in Group B were much more likely to have a leg-dominant pain (p = 0.0088) and had significantly higher Oswestry Disability Index (p = 0.0121) and EuroQol-5D mobility (p = 0.0484) scores.

Conclusions

The SSP significantly reduced MRI utilization and referrals seen by the surgeon for nonoperative care. Although this early implementation study suggests potential for cost savings, a more rigorous analysis of outcomes, costs, and patient satisfaction is required.

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Daryl R. Fourney and Ziya L. Gokaslan

Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.

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Daryl R. Fourney and Ziya L. Gokaslan

In addition to tumor resection, a major goal of spine surgery involving tumors is the preservation or achievement of spinal stability. The criteria defining stability, originally developed for use in trauma, are not directly applicable in the setting of neoplasia. The authors discuss the most common patterns of tumor-related instability and deformity at all levels of the spinal column and review the surgical options for treatment.

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Use of “MAPS” for determining the optimal surgical approach to metastatic disease of the thoracolumbar spine: anterior, posterior, or combined

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Daryl R. Fourney and Ziya L. Gokaslan

✓ The surgical treatment of thoracolumbar metastases is controversial, and various approaches have been described. No single approach, however, is always applicable, and the optimal surgical strategy for any individual is determined by several interrelated factors. The authors have grouped these factors into four preoperative planning considerations that form the mnemonic “MAPS”: 1) method of resection; 2) anatomy of spinal disease; 3) patient's level of fitness; and 4) stabilization. The choice of approach is also considered in light of the goals of surgery, including the relief of pain, neurological palliation, spinal stabilization, and oncological control.

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Adam S. Wu and Daryl R. Fourney

Object

Routine histopathological examination of discectomy specimens remains common practice in many hospitals, although it rarely detects unsuspected clinically significant disease. Controversy exists as to the effectiveness of this practice. The objectives of this study were to compare the authors’ experience with a review of the literature.

Methods

In a retrospective database analysis the authors identified all intervertebral disc specimens obtained during spinal procedures over an 8-year period (1996–2004). Cases of benign (nonneoplastic and noninfectious) indications for surgery were included in the study, whereas cases of nonbenign indications were excluded. The final pathological diagnoses were reviewed, and a chart review was performed to determine whether any unexpected findings affected subsequent patient care. A total of 1858 discectomy specimens were identified: 1775 of these were obtained in 1719 routine discectomy procedures. Unexpected histopathological findings were identified in four cases, and none was clinically significant.

Conclusions

Routine histopathological examination of disc specimens is not justified. The decision to send specimens for pathological examination should be determined on a case-by-case basis after consideration of the clinical presentation, results of laboratory and imaging studies, and intraoperative findings.

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Daryl R. Fourney, Gregory N. Fuller and Ziya L. Gokaslan

✓ Extradural ependymomas of the sacrococcygeal region are very rare, with most arising from the soft tissues of the presacral area or from the regions dorsal to the sacrum. In even rarer circumstances, the tumor may arise within the sacral canal, likely as a result of ependymal cells of the extradural filum terminale. Because of bone erosion caused by extension of the tumor into the pelvis or dorsal to the sacrum, a truly intraspinal extradural ependymoma in this region has until now never been clearly demonstrated. The authors present a patient with a myxopapillary ependymoma arising from the filum terminale externa in which there was no involvement of the intradural filum or extension outside the sacral canal. A review of the literature is presented, with emphasis on the pathogenesis and clinical management of these rare tumors.

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Daryl R. Fourney, Dima Abi-Said, Frederick F. Lang, Ian E. McCutcheon and Ziya L. Gokaslan

Object. Few reports are available on the use of pedicle screw fixation for cancer-related spinal instability. The authors present their experience with pedicle screw fixation in the management of malignant spinal column tumors.

Methods. Records for patients with malignant spinal tumors who underwent pedicle screw fixation at the authors' institution between September 1994 and December 1999 were retrospectively reviewed.

Results. Ninety-five patients with malignant spinal tumors underwent 100 surgeries involving pedicle screw fixation: metastatic spinal disease was present in 81 patients, and locally invasive tumors were demonstrated in 14 patients. Indications for surgery were pain (98%) and/or neurological dysfunction (80%). A posterior (48%) or a combined anterior—posterior (52%) approach was performed depending on the extent of tumor and the patient's condition. At the mean follow up of 8.2 months, 43 patients (45%) had died; median survival, as determined by Kaplan—Meier analysis, was 14.8 months. At 1 month postsurgery, self-reported pain had improved in 87% of cases (p < 0.001), which is a finding substantiated by reductions in analgesic use, and 29 (47%) of 62 patients with preoperative neurological impairments were functionally improved (p < 0.001). Postoperative complications were associated only with preoperative radiation therapy (p = 0.002) and with preexisting serious medical conditions (p = 0.04). In two patients asymptomatic violation of the lateral wall of the pedicle was revealed on postoperative radiography. The 30-day mortality rate was 1%.

Conclusions. For selected patients with malignant spinal tumors, pedicle screw fixation after tumor resection may provide considerable pain relief and restore or preserve ambulation with acceptable rates of morbidity and mortality.

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Adam S. Wu, Robert W. Griebel, Kotoo Meguro and Daryl R. Fourney

Spinal subdural empyema is an exceptionally rare and serious condition. Immediate surgery with complete exposure and drainage of the abscess is generally recommended. The authors present a patient in whom a Staphylococcus aureus septicemia related to nosocomial pneumonia developed after a thoracic laminectomy. The surgery was further complicated by an unintended durotomy (dural tear). Ten days postoperatively, the patient experienced back pain and lower-extremity symptoms caused by a subdural empyema. Cultures from the wound also grew S. aureus. This represents the first case of spinal subdural empyema in which the spread of infection into the subdural space is believed to have been facilitated by a dural tear. The patient had a favorable outcome despite an initial delay in surgical intervention because of a pulmonary embolus.

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Lissa Peeling, Evan Frangou, Stephen Hentschel, Ziya L. Gokaslan and Daryl R. Fourney

The treatment of complex thoracolumbar disorders occasionally requires combined anterior and posterior approaches. Traditionally, these are either sequentially staged to occur during the same anesthesia procedure or alternatively performed on separate days. A less common option is the simultaneous anterior-posterior approach. The authors discuss the rationale for this approach in selected cases and illustrate a number of modifications to previous descriptions of the procedure. By slightly altering the incision, the risk of wound breakdown and infection has been reduced. The use of newly available positioning devices has allowed easy incorporation of fluoroscopy to guide the placement of spinal instrumentation. The authors have also expanded the use of the approach beyond the original oncological indications to include trauma and infection.

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Stephen J. Hentschel, Allen W. Burton, Daryl R. Fourney, Laurence D. Rhines and Ehud Mendel

Object. The purpose of this study was to examine a group of patients with cancer who underwent a vertebroplasty or a kyphoplasty for a vertebral body (VB) fracture, even though the procedure may have been considered contraindicated based on previous reports in the literature.

Methods. The electronic database maintained by the Departments of Neurosurgery and Anesthesiology—Pain Management at the University of Texas M. D. Anderson Cancer Center was searched for patients who underwent vertebroplasty or kyphoplasty between January 2001 and July 2003. The criteria defining a contraindicated procedure were based on a review of the literature. Group I consisted of patients who did not undergo a contraindicated vertebroplasty or kyphoplasty, whereas Group II consisted of patients who underwent one of these procedures even though it may have been considered contraindicated.

There were 53 patients with fractures at 132 levels who met the criteria for the study. Of these, 17 patients with fractures at 18 levels (14% of total) were considered to have undergone a contraindicated vertebroplasty or kyphoplasty (Group II). There were 12 complications (11%) in the 114 levels in Group I and seven complications (39%) in the 18 levels in Group II (p = 0.03). The most common complication was cement extrusion from the anterior VB that did not involve the venous system. No patient required an open surgical procedure to remove extruded cement.

Conclusions. Vertebroplasty and kyphoplasty appear to be safe and effective in the setting of severe back pain caused by VB fracture that is unresponsive to other therapies, even in the presence of relative contraindications to the procedures.