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nlm-article

Bo Li, Gregory A. Kuzmik, Saman Shabani, Nitin Agarwal, Alysha Jamieson, Thomas Wozny, Simon Ammanuel, Praveen V. Mummaneni, and Dean Chou

It can be difficult to avoid violating the pleura during the retropleural approach to the thoracolumbar spine. In this video, the authors resect a short segment of rib to allow more room for pleural dissection during a minimally invasive (MIS) lateral retropleural approach. After a lateral MIS skin incision, the rib is dissected and removed, clearly identifying the retropleural space. The curvature of the rib can then be followed, decreasing the risk of pleural violation. The pleura can then be mobilized ventrally until the spine is accessed. Managing the diaphragm is also illustrated by separating the fibers without a traditional cut through the muscle.

The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID21138

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nlm-article

Enrique Vargas, Dennis T. Lockney, Praveen V. Mummaneni, Alexander F. Haddad, Joshua Rivera, Xiao Tan, Alysha Jamieson, Yasmine Mahmoudieh, Sigurd Berven, Steve E. Braunstein, and Dean Chou

OBJECTIVE

Within the Spine Instability Neoplastic Score (SINS) classification, tumor-related potential spinal instability (SINS 7–12) may not have a clear treatment approach. The authors aimed to examine the proportion of patients in this indeterminate zone who later required surgical stabilization after initial nonoperative management. By studying this patient population, they sought to determine if a clear SINS cutoff existed whereby the spine is potentially unstable due to a lesion and would be more likely to require stabilization.

METHODS

Records from patients treated at the University of California, San Francisco, for metastatic spine disease from 2005 to 2019 were retrospectively reviewed. Seventy-five patients with tumor-related potential spinal instability (SINS 7–12) who were initially treated nonoperatively were included. All patients had at least a 1-year follow-up with complete medical records. A univariate chi-square test and Student t-test were used to compare categorical and continuous outcomes, respectively, between patients who ultimately underwent surgery and those who did not. A backward likelihood multivariate binary logistic regression model was used to investigate the relationship between clinical characteristics and surgical intervention. Recursive partitioning analysis (RPA) and single-variable logistic regression were performed as a function of SINS.

RESULTS

Seventy-five patients with a total of 292 spinal metastatic sites were included in this study; 26 (34.7%) patients underwent surgical intervention, and 49 (65.3%) did not. There was no difference in age, sex, comorbidities, or lesion location between the groups. However, there were more patients with a SINS of 12 in the surgery group (55.2%) than in the no surgery group (44.8%) (p = 0.003). On multivariate analysis, SINS > 11 (OR 8.09, CI 1.96–33.4, p = 0.004) and Karnofsky Performance Scale (KPS) score < 60 (OR 0.94, CI 0.89–0.98, p = 0.008) were associated with an increased risk of surgery. KPS score was not correlated with SINS (p = 0.4). RPA by each spinal lesion identified an optimal cutoff value of SINS > 10, which were associated with an increased risk of surgical intervention. Patients with a surgical intervention had a higher incidence of complications on multivariable analysis (OR 2.96, CI 1.01–8.71, p = 0.048).

CONCLUSIONS

Patients with a mean SINS of 11 or greater may be at increased risk of mechanical instability requiring surgery after initial nonoperative management. RPA showed that patients with a KPS score of 60 or lower and a SINS of greater than 10 had increased surgery rates.