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  • Author or Editor: Frank D. Vrionis x
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Kamran Aghayev and Frank D. Vrionis

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Frank D. Vrionis and John Small

Object

In this study the authors retrospectively review outcomes in patients treated for metastases to the spine. Surgery for metastatic tumors to the spine remains an important part of the treatment armamentarium. Maximum tumor resection with a minimum number of complications is one of the goals of surgery. Current surgical procedures include tumor resection and spinal stabilization for optimal results.

Methods

The records of 96 patients who underwent surgery for a metastatic spine tumor at the authors' institution were reviewed. Spinal instrumentation was used in the majority of patients. Ambulatory status was maintained in 91% and pain improved in 94% of patients. Complications included infection (5.2%), cerebrospinal fluid leak (2%), and delayed hardware failure (3.1%). The mortality rate was 4.1%; the main cause was due to tumor progression.

Conclusions

Surgery is indicated in a select group of patients with metastatic tumors to the spine. A multidisciplinary approach is recommended for patient selection and complication avoidance. Surgical options, including approach, type of reconstruction and extent of resection (including en bloc spondylectomy) need to be addressed for optimal outcomes.

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Matthias Setzer, Mohamed Eleraky, Wesley M. Johnson, Kamran Aghayev, Nam D. Tran and Frank D. Vrionis

Object

The objective of this study was to compare the stiffness and range of motion (ROM) of 4 cervical spine constructs and the intact condition. The 4 constructs consisted of 3-level anterior cervical discectomy with anterior plating, 1-level discectomy and 1-level corpectomy with anterior plating, 2-level corpectomy with anterior plating, and 2-level corpectomy with anterior plating and posterior fixation.

Methods

Eight human cadaveric fresh-frozen cervical spines from C2–T2 were used. Three-dimensional motion analysis with an optical tracking device was used to determine motion following various reconstruction methods. The specimens were tested in the following conditions: 1) intact; 2) segmental construct with discectomies at C4–5, C5–6, and C6–7, with polyetheretherketone (PEEK) interbody cage and anterior plate; 3) segmental construct with discectomy at C6–7 and corpectomy of C-5, with PEEK interbody graft at the discectomy level and a titanium cage at the corpectomy level; 4) corpectomy at C-5 and C-6, with titanium cage and an anterior cervical plate; and 5) corpectomy at C-5 and C-6, with titanium cage and an anterior cervical plate, and posterior lateral mass screw-rod system from C-4 to C-7. All specimens underwent a pure moment application of 2 Nm with regards to flexion-extension, lateral bending, and axial rotation.

Results

In all tested motions the statistical comparison was significant between the intact condition and the 2-level corpectomy with anterior plating and posterior fixation construct. All other statistical comparisons between the instrumented constructs were not statistically significant except between the 3-level discectomy with anterior plating and the 2-level corpectomy with anterior plating in axial rotation. There were no statistically significant differences between the 1-level discectomy and 1-level corpectomy with anterior plating and the 2-level corpectomy with anterior plating in any tested motion. There was also no statistical significance between the 3-level discectomy with anterior plating and the 2-level corpectomy with anterior plating and posterior fixation.

Conclusions

This study demonstrates that segmental plate fixation (3-level discectomy) affords the same stiffness and ROM as circumferential fusion in 2-level cervical spine corpectomy in the immediate postoperative setting. This obviates the need for staged circumferential procedures for multilevel cervical spondylotic myelopathy. Given that the posterior segmental instrumentation confers significant stability to a multilevel cervical corpectomy, the surgeon should strongly consider the placement of segmental posterior instrumentation to significantly improve the overall stability of the fusion construct after a 2-level cervical corpectomy.

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Mohammed Eleraky, Ioannis Papanastassiou, Matthias Setzer, Ali A. Baaj, Nam D. Tran and Frank D. Vrionis

Object

Balloon kyphoplasty has recently been shown to be effective in providing rapid pain relief and enhancing health-related quality of life in patients with metastatic spinal tumors. When performed to treat lesions of the upper thoracic spine, kyphoplasty poses certain technical challenges because of the smaller size of the pedicle and vertebral bodies. Fluoroscopic visualization is also difficult due to interference of the shoulder. The authors' objective in the present study was to evaluate their approach and the results of balloon kyphoplasty in the upper thoracic spine in patients with metastatic spinal disease.

Methods

Fourteen patients underwent kyphoplasty via an extrapedicular approach to treat metastatic tumors in the upper (T1–5) thoracic spine. Electrodiagnostic monitoring (somatosensory and motor evoked potentials) was used in 5 cases. Three levels were treated in 7 cases, 2 levels in 2 cases, and 1 level in 5 cases. In 3 cases access was bilateral, whereas in 11 cases access was unilateral. The procedure took an average of 25 minutes per treated level, and the mean amount of cement applied was 3 ml per level. Four patients were discharged from the hospital on the day of the procedure, and 10 patients went home after 24 hours.

Results

All patients exhibited marked improvement in mean visual analog scale scores (preoperative score 79 vs postoperative score 30, respectively) and Oswestry Disability Index scores (83 vs 33, respectively). The mean kyphotic angle was 25.03° preoperatively, whereas the mean postoperative angle was 22.65° (p > 0.3). At latest follow-up, the mean kyphotic angle did not differ significantly from the postoperative kyphotic angle (26.3°, p > 0.1).

No neurological deficits or lung-related complications (pneumothorax or hemothorax) were encountered in any of the patients. Polymethylmethacrylate cement extravasations were observed in 3 (10%) of 30 treated vertebral bodies without any sequelae. By a mean follow-up of 16 months, no patients had experienced an adjacent-level fracture.

Conclusions

Balloon kyphoplasty of the upper thoracic spine via an extrapedicular approach is an efficient and safe minimally invasive procedure that may provide immediate and long-term pain relief and improvement in functional ability. It is technically challenging and has the potential for serious complications. With a fundamental knowledge of anatomy, as well as an ability to interpret fluoroscopy images, one can feasibly and safely perform balloon kyphoplasty in the upper thoracic spine.

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Matthias Setzer, Frank D. Vrionis, Elvis J. Hermann, Volker Seifert and Gerhard Marquardt

Object

The authors examined a possible association between apolipoprotein E (APOE) gene polymorphism and the outcome after anterior microsurgical decompression in patients with cervical spondylotic myelopathy (CSM).

Methods

The authors conducted a prospective study of 60 consecutive patients (40 men, 20 women) with CSM who underwent anterior microsurgical decompression. The patients ranged in age from 26 to 86 years (mean 61.5 ± 14.6 years). Neurological deficits were classified according to the modified Japanese Orthopaedic Association Scale. Mean follow-up was 18.8 ± 4.6 months and APOE genotyping was carried out by isolation of DNA from venous blood samples. The APOE genotypes were determined by polymerase chain reaction followed by restriction enzyme digestion and polyacrylamide gel electrophoresis of digested fragments. Categorical variables were analyzed with the chi-square test, continuous data with the Mann-Whitney U-test, and for multiple groups with the Kruskal-Wallis H-test. A backward stepwise binary logistic regression analysis was performed to determine the effect of APOE in a multivariate model.

Results

Of the 60 patients with CSM, 35 (58.3%) improved and 25 (41.7%) did not improve or suffered deterioration (no-improvement group). In the improvement group 5 patients (8.3%) possessed the ε4 allele compared with 16 patients (26.7%) in the no-improvement group (p = 0.002, OR 3.3, 95% CI 1.7–6.1). In a multivariate model, the occurrence of the ε4 allele was a significant independent predictor for no improvement after anterior decompression and fusion (p = 0.004, OR 8.6, 95% CI 5.1–20.6).

Conclusions

The results of this study show that APOE gene polymorphism influences the short-term outcome of CSM patients after surgical decompressive and stabilizing therapy in the way that the presence of the APOE ε4 allele is an independent predictor for a no improvement. The presence of APOE may explain in part the different responses to operative therapies in patients with cervical myelopathy.

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Andreas K. Filis, Kamran Aghayev, Bernhard Schaller, Jennifer Luksza and Frank D. Vrionis

Kyphoplasty and vertebroplasty are established treatment methods to reinforce fractured vertebral bodies. In cases of previous pedicle screw instrumentation, vertebral body cannulation may be challenging. The authors describe, for the first time, an approach through the adjacent inferior vertebra and disc space in the thoracic spine for cement augmentation. A 78-year-old woman underwent posterior fusion with pedicle screws after vertebrectomy and reconstruction with cement and Steinmann pins for a pathological T-7 fracture. Two months later she developed a compression fracture of the vertebral body at the lower part of the construct, and a vertebroplasty was performed. Because a standard transpedicular route was not available, an inferior transdiscal trajectory was used for the cement injection. A 73-year-old man with a history of rheumatoid arthritis underwent cervicothoracic fusion posteriorly for subluxation. He developed pain in the upper thoracic area, and the authors performed a transdiscal vertebroplasty at T-2. The standard transpedicular route was not possible. The vertebral body was satisfactorily filled up with cement. Clinically both patients benefited significantly in terms of back pain and showed an uneventful follow-up of 3 months. Transdiscal vertebroplasty can achieve good results in the mid- and upper thoracic spine when a standard transpedicular trajectory is not possible, and can therefore be a good alternative in select cases.

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Christopher P. Ames, Vincent Y. Wang, Vedat Deviren and Frank D. Vrionis

Management of metastatic disease is a significant challenge in modern spinal surgery. Previously, radiation therapy alone was the most commonly employed treatment. Recent data, however, suggest that surgical decompression in addition to radiation therapy improves functional recovery compared with radiation therapy alone.

Metastatic disease most commonly affects the thoracic spine. Over the past decade surgical treatment has changed significantly for thoracic disease, shifting from transthoracic resection and reconstruction to single-stage posterolateral approaches that allow transpedicular resection and reconstruction. In posterolateral approaches, patients are spared the morbidity associated with transcavitary approaches while receiving the benefit of radical resection and circumferential reconstruction in a single-stage procedure.

The authors report 3 cases in which a similar posterior transpedicular technique, adapted for the cervical spine, was used for intralesional resection of metastatic tumors of the axis.

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Matthias Setzer, Hartmut Vatter, Gerhard Marquardt, Volker Seifert and Frank D. Vrionis

Object

In this report, the authors describe their experience in the surgical management of spinal meningiomas at two neurosurgical centers. The results of a literature review are also presented.

Methods

Eighty consecutive patients (22 men and 58 women) with spinal meningiomas who had undergone an operation at two specific neurosurgical centers were included in this study. Functional outcomes were evaluated using univariate and multivariate analyses. A review of the literature yielded an additional 651 patients with spinal meningiomas from 9 large studies.

Results

On multivariate analysis, the variable of a poor preoperative neurological state (p < 0.02, odds ratio [OR] 13.6, 95% confidence interval [CI] 2.6–71.4) and invasion of the arachnoid/pia mater (p < 0.03, OR 15.2, 95% CI 2.5–90.4) were independent predictors of a poor outcome, whereas invasion of the arachnoid/pia (p < 0.02, OR 8.9, 95% CI 2.2–35) and duration of symptoms (p < 0.001, OR 1.12/month, 95% CI 1.05–1.2) predicted no improvement (stable or deteriorated condition). The Cox proportional hazards regression analysis showed three significant predictor variables for recurrence: invasion of the arachnoid/pia (p < 0.05; hazard ratio [HR] 1.8, 95% CI 1.2–3.6), Simpson resection grade (p < 0.012, HR 6.8, 95% CI 1.5–3.0), and histological tumor grade (Grade I; p < 0.001, HR 0.001–0.17).

Conclusions

Because of the excellent outcome of surgery for benign spinal meningiomas and the association between duration of symptoms and neurological compromise with a poor functional outcome, early operation is the treatment of choice. In cases of malignant transformation, adjuvant therapies must be considered.

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Mohammed Eleraky, Matthias Setzer, Ali A. Baaj, Ioannis Papanastassiou, Bryan P. Conrad and Frank D. Vrionis

Object

Posterior instrumentation is the preferred method of fixation in the unstable cervicothoracic junction (CTJ). Several posterior rod constructs of different diameters and configurations are available for instrumentation across the CTJ. The objective of this study was to compare the biomechanical stability of various posterior instrumentation techniques that cross the CTJ after a 2-column injury through the complete removal of the posterior elements at C-7.

Methods

Eight fresh-frozen human cadaveric spines (C3–T4) were used. After the intact spine analysis, each specimen was destabilized (C-7 laminectomy and bilateral facetectomies) and reconstructed as follows: Group 1, C5–T2 posterior instrumentation with a 3.5-mm rod; Group 2, C5–T2 posterior instrumentation with a transitional rod (3.5–5.5 mm); and Group 3, C5–T2 posterior instrumentation with a side-to-side rod connector (3.5–5.5 mm). All reconstructed groups were tested with posterior instrumentation using the Cervifix system (Synthes, Inc.). The authors hypothesized that Group 2 would be the most stable.

Results

Following laminectomy, facetectomy, and the application of instrumentation, there was a decrease in the range of motion in all treatment groups compared with the intact spine. This trend was observed in all 3 planes of motion, but was only significant on right/left lateral bending and flexion (for the transitional rod only). Although the instrumented spines were stiffer than the intact spine in right/left axial rotation, flexion, and extension, these differences did not reach statistical significance. Based on observations during testing, it was evident that in the implanted spines, most of the motion that did occur was localized at the segments adjacent to the instrumented levels.

Conclusions

Based on the results of this investigation, the biomechanical stability of the transitional rod, side-to-side connector (“wedding band”), and 3.5-mm rods appears to be similar.

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Matthias Setzer, Ryan D. Murtagh, F. Reed Murtagh, Mohammed Eleraky, Surbhi Jain, Gerhard Marquardt, Volker Seifert and Frank D. Vrionis

Object

The aim of this retrospective study was to evaluate the predictive value of diffusion tensor (DT) imaging with respect to resectability of intramedullary spinal cord tumors and to determine the concordance of this method with intraoperative surgical findings.

Methods

Diffusion tensor imaging was performed in 14 patients with intramedullary lesions of the spinal cord at different levels using a 3-T magnet. Routine MR imaging scans were also obtained, including unenhanced and enhanced T1-weighted images and T2-weighted images. Patients were classified according to the fiber course with respect to the lesion and their lesions were rated as resectable or nonresectable. These results were compared with the surgical findings (existence vs absence of cleavage plane). The interrater reliability was calculated using the κ coefficient of Cohen.

Results

Of the 14 patients (7 male, 7 female; mean age 49.2 ± 15.5 years), 13 had tumors (8 ependymomas, 2 lymphomas, and 3 astrocytoma). One lesion was proven to be a multiple sclerosis plaque during further diagnostic workup. The lesions could be classified into 3 types according to the fiber course. In Type 1 (5 cases) fibers did not pass through the solid lesion. In Type 2 (3 cases) some fibers crossed the lesion, but most of the lesion volume did not contain fibers. In Type 3 (6 cases) the fibers were completely encased by tumor. Based on these results, 6 tumors were considered resectable, 7 were not. During surgery, 7 tumors showed a good cleavage plane, 6 did not. The interrater reliability (Cohen κ) was calculated as 0.83 (p < 0.003), which is considered to represent substantial agreement. The mean duration of follow-up was 12.0 ± 2.9. The median McCormick grade at the end of follow-up was II.

Conclusions

These preliminary data suggest that DT imaging in patients with spinal cord tumors is capable of predicting the resectability of the lesion. A further prospective study is needed to confirm these results and any effect on patient outcome.