Publications by authors named "Aron Lazary"

82 Publications

Calculating Utilities From the Spine Oncology Study Group Outcomes Questionnaire: A Necessity for Economic and Decision Analysis.

Spine (Phila Pa 1976) 2021 Sep;46(17):1165-1171

Division of Spine, Surgery Vancouver Spine Surgery Institute, Vancouver General Hospital University of British Columbia, Vancouver, Canada.

Study Design: General population utility valuation study.

Objective: The aim of this study was to develop a technique for calculating utilities from the Spine Oncology Study Group Outcomes Questionnaire v2.0 (SOSGOQ2.0).

Summary Of Background Data: The ability to calculate quality-adjusted life-years (QALYs) for metastatic spine disease would enhance treatment decision-making and facilitate economic analysis. QALYs are calculated using utilities.

Methods: Using a hybrid concept-retention and factorial analysis shortening approach, we first shortened the SOSGOQ2.0 to eight items (SOSGOQ-8D). This was done to lessen the cognitive burden of the utility valuation exercise. A general population sample of 2730 adults was then asked to evaluate 12 choice sets based on SOSGOQ-8D health states in a Discrete Choice Experiment. A utility scoring rubric was then developed using a mixed multinomial-logit regression model.

Results: We were able to reduce the SOSGOQ2.0 to an SOSGOQ-8D with a mean error of 0.003 and mean absolute error of 3.078 compared to the full questionnaire. The regression model demonstrated good predictive performance and was used to develop a utility scoring rubric. Regression results revealed that participants did not regard all SOSGOQ-8D items as equally important.

Conclusion: We provide a simple technique for converting the SOSGOQ2.0 to utilities. The ability to evaluate QALYs in metastatic spine disease will facilitate economic analysis and patient counseling. We also quantify the importance of individual SOSGOQ-8D items. Clinicians should heed these findings and offer treatments that maximize function in the most important items.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357033PMC
September 2021

Correlation Between the Spinal Instability Neoplastic Score (SINS) and Patient Reported Outcomes.

Global Spine J 2021 Jul 26:21925682211033591. Epub 2021 Jul 26.

Research Department, AO Spine International, Davos, Switzerland.

Study Design: International multicenter prospective observational cohort study on patients undergoing radiation +/- surgical intervention for the treatment of symptomatic spinal metastases.

Objectives: To investigate the association between the total Spinal Instability Neoplastic Score (SINS), individual SINS components and PROs.

Methods: Data regarding patient demographics, diagnostics, treatment, and PROs (SF-36, SOSGOQ, EQ-5D) was collected at baseline, 6 weeks, and 12 weeks post-treatment. The SINS was assessed using routine diagnostic imaging. The association between SINS, PRO at baseline and change in PROs was examined with the Spearmans rank test.

Results: A total of 307 patients, including 174 patients who underwent surgery+/- radiotherapy and 133 patients who underwent radiotherapy were eligible for analyses. In the surgery+/- radiotherapy group, 18 (10.3%) patients with SINS score between 0-6, 118 (67.8%) with a SINS between 7-12 and 38 (21.8%) with a SINS between 13-18, as compared to 55 (41.4%) SINS 0-6, 71(53.4%) SINS 7-12 and 7 (5.2%) SINS 13-18 in the radiotherapy alone group. At baseline, the total SINS and the presence of mechanical pain was significantly associated with the SOSGOQ pain domain (r = -0.519, < 0.001) and the NRS pain score (r = 0.445, < 0.001) for all patients. The presence of mechanical pain demonstrated to be moderately associated with a positive change in PROs at 12 weeks post-treatment.

Conclusion: Spinal instability, as defined by the SINS, was significantly correlated with PROs at baseline and change in PROs post-treatment. Mechanical pain, as a single SINS component, showed the highest correlations with PROs.
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http://dx.doi.org/10.1177/21925682211033591DOI Listing
July 2021

Complicated Postoperative Flat Back Deformity Correction With the Aid of Virtual and 3D Printed Anatomical Models: Case Report.

Front Surg 2021 28;8:662919. Epub 2021 May 28.

Department of Industrial Engineering, Alma Mater Studiorum, Universita di Bologna, Bologna, Italy.

The number of patients with iatrogenic spinal deformities is increasing due to the increase in instrumented spinal surgeries globally. Correcting a deformity could be challenging due to the complex anatomical and geometrical irregularities caused by previous surgeries and spine degeneration. Virtual and 3D printed models have the potential to illuminate the unique and complex anatomical-geometrical problems found in these patients. We present a case report with 6-months follow-up (FU) of a 71 year old female patient with severe sagittal and coronal malalignment due to repetitive discectomy, decompression, laminectomy, and stabilization surgeries over the last 39 years. The patient suffered from severe low back pain (VAS = 9, ODI = 80). Deformity correction by performing asymmetric 3-column pedicle subtraction osteotomy (PSO) and stabilization were decided as the required surgical treatment. To better understand the complex anatomical condition, a patient-specific virtual geometry was defined by segmentation based on the preoperative CT. The geometrical accuracy was tested using the Dice Similarity Index (DSI). A complex 3D virtual plan was created for the surgery from the segmented geometry in addition to a 3D printed model. The segmentation process provided a highly accurate geometry (L1 to S2) with a DSI value of 0.92. The virtual model was shared in the internal clinical database in 3DPDF format. The printed physical model was used in the preoperative planning phase, patient education/communication and during the surgery. The surgery was performed successfully, and no complications were registered. The measured change in the sagittal vertical axis was 7 cm, in the coronal plane the distance between the C7 plumb line and the central sacral vertical line was reduced by 4 cm. A 30° correction was achieved for the lumbar lordosis due to the PSO at the L4 vertebra. The patient ODI was reduced to 20 points at the 6-months FU. The printed physical model was considered advantageous by the surgical team in the pre-surgical phase and during the surgery as well. The model was able to simplify the geometrical problems and potentially improve the outcome of the surgery by preventing complications and reducing surgical time.
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http://dx.doi.org/10.3389/fsurg.2021.662919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192795PMC
May 2021

Feasibility of achieving planned surgical margins in primary spine tumor: a PTRON study.

Neurosurg Focus 2021 05;50(5):E16

1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada.

Objective: Oncological resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, the execution of a meticulously drafted plan sometimes fails. The objectives of this study were to determine how successful surgical teams are at achieving planned surgical margins and how successful surgeons are in intraoperatively assessing tumor margins. The secondary objective was to identify factors associated with successful execution of planned resection.

Methods: The Primary Tumor Research and Outcomes Network (PTRON) is a multicenter international prospective registry for the management of primary tumors of the spine. Using this registry, the authors compared 1) the planned surgical margin and 2) the intraoperative assessment of the margin by the surgeon with the postoperative assessment of the margin by the pathologist. Univariate analysis was used to assess whether factors such as histology, size, location, previous radiotherapy, and revision surgery were associated with successful execution of the planned margins.

Results: Three hundred patients were included. The surgical plan was successfully achieved in 224 (74.7%) patients. The surgeon correctly assessed the intraoperative margins, as reported in the final assessment by the pathologist, in 239 (79.7%) patients. On univariate analysis, no factor had a statistically significant influence on successful achievement of planned margins.

Conclusions: In high-volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with the expected success rate in order to optimize patient management and surgical decision-making.
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http://dx.doi.org/10.3171/2021.2.FOCUS201091DOI Listing
May 2021

A novel three-dimensional volumetric method to measure indirect decompression after percutaneous cement discoplasty.

J Orthop Translat 2021 May 1;28:131-139. Epub 2021 Apr 1.

Department of Spine Surgery, Semmelweis University, Budapest, Hungary.

Purpose: Percutaneous cement discoplasty (PCD) is a minimally invasive surgical option to treat patients who suffer from the consequences of advanced disc degeneration. As the current two-dimensional methods can inappropriately measure the difference in the complex 3D anatomy of the spinal segment, our aim was to develop and apply a volumetric method to measure the geometrical change in the surgically treated segments.

Methods: Prospective clinical and radiological data of 10 patients who underwent single- or multilevel PCD was collected. Pre- and postoperative CT scan-based 3D reconstructions were performed. The injected PMMA (Polymethylmethacrylate) induced lifting of the cranial vertebra and the following volumetric change was measured by subtraction of the geometry of the spinal canal from a pre- and postoperatively predefined cylinder. The associations of the PMMA geometry and the volumetric change of the spinal canal with clinical outcome were determined.

Results: Change in the spinal canal volume (ΔV) due to the surgery proved to be significant (mean ΔV = 2266.5 ± 1172.2 mm, n = 16; p = 0.0004). A significant, positive correlation was found between ΔV, the volume and the surface of the injected PMMA. A strong, significant association between pain intensity (low back and leg pain) and the magnitude of the volumetric increase of the spinal canal was shown (ρ = 0.772, p = 0.009 for LBP and ρ = 0.693, p = 0.026 for LP).

Conclusion: The developed method is accurate, reproducible and applicable for the analysis of any other spinal surgical method. The volume and surface area of the injected PMMA have a predictive power on the extent of the indirect spinal canal decompression. The larger the ΔV the higher clinical benefit was achieved with the PCD procedure.

The Translational Potential Of This Article: The developed method has the potential to be integrated into clinical software's to evaluate the efficacy of different surgical procedures based on indirect decompression effect such as PCD, anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), oblique lumbar interbody fusion (OLIF), extreme lateral interbody fusion (XLIF). The intraoperative use of the method will allow the surgeon to respond if the decompression does not reach the desired level.
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http://dx.doi.org/10.1016/j.jot.2021.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050383PMC
May 2021

Development of a Computer-Aided Design and Finite Element Analysis Combined Method for Affordable Spine Surgical Navigation With 3D-Printed Customized Template.

Front Surg 2020 25;7:583386. Epub 2021 Jan 25.

National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.

Revision surgery of a previous lumbosacral non-union is highly challenging, especially in case of complications, such as a broken screw at the first sacral level (S1). Here, we propose the implementation of a new method based on the CT scan of a clinical case using 3D reconstruction, combined with finite element analysis (FEA), computer-assisted design (CAD), and 3D-printing technology to provide accurate surgical navigation to aid the surgeon in performing the optimal surgical technique by inserting a pedicle screw at the S1 level. A step-by-step approach was developed and performed as follows: (1) Quantitative CT based patient-specific FE model of the sacrum was created. (2) The CAD model of the pedicle screw was inserted into the sacrum model in a bicortical convergent and a monocortical divergent position, by overcoming the geometrical difficulty caused by the broken screw. (3) Static FEAs (Abaqus, Dassault Systemes) were performed using 500 N tensile load applied to the screw head. (4) A template with two screw guiding structures for the sacrum was designed and manufactured using CAD design and 3D-printing technologies, and investment casting. (5) The proposed surgical technique was performed on the patient-specific physical model created with the FDM printing technology. The patient-specific model was CT scanned and a comparison with the virtual plan was performed to evaluate the template accuracy FEA results proved that the modified bicortical convergent insertion is stiffer (6,617.23 N/mm) compared to monocortical divergent placement (2,989.07 N/mm). The final template was created via investment casting from cobalt-chrome. The template design concept was shown to be accurate (grade A, Gertzbein-Robbins scale) based on the comparison of the simulated surgery using the patient-specific physical model and the 3D virtual surgical plan. Compared to the conventional surgical navigation techniques, the presented method allows the consideration of the patient-specific biomechanical parameters; is more affordable, and the intraoperative X-ray exposure can be reduced. This new patient- and condition-specific approach may be widely used in revision spine surgeries or in challenging primary cases after its further clinical validation.
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http://dx.doi.org/10.3389/fsurg.2020.583386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873739PMC
January 2021

Health related quality of life outcomes following surgery and/or radiation for patients with potentially unstable spinal metastases.

Spine J 2021 03 22;21(3):492-499. Epub 2020 Oct 22.

Research Department, AOSpine International, Davos, Switzerland.

Background: Currently there is no prospective pain and health related quality of life (HRQOL) data of patients with potentially unstable spinal metastases who were treated with surgery ± radiation or radiation alone.

Methods: An international prospective cohort multicenter study of patients with potentially unstable spinal metastases, defined by a SINS score 7 to 12, treated with surgery ± radiation or radiotherapy alone was conducted. HRQOL was evaluated with the numeric rating scale (NRS) pain score, the SOSGOQ2.0, the SF-36, and the EQ-5D at baseline and 6, 12, 26, and 52 weeks after treatment.

Results: A total of 136 patients were treated with surgery ± radiotherapy and 84 with radiotherapy alone. At baseline, surgically treated patients were more likely to have mechanical pain, a lytic lesion, a greater median Spinal Instability Neoplastic score, vertebral compression fracture, lower performance status, HRQOL, and pain scores. From baseline to 12 weeks post-treatment, surgically treated patients experienced a 3.0-point decrease in NRS pain score (95% CI -4.1 to -1.9, p<.001), and a 12.7-point increase in SOSGOQ2.0 score (95% CI 6.3-19.1, p<.001). Patients treated with radiotherapy alone experienced a 1.4-point decrease in the NRS pain score (95% CI -2.9 to 0.0, p=.046) and a 6.2-point increase in SOSGOQ2.0 score (95% CI -2.0 to 14.5, p=.331). Beyond 12 weeks, significant improvements in pain and HRQOL metrics were maintained up to 52-weeks follow-up in the surgical cohort, as compared with no significant changes in the radiotherapy alone cohort.

Conclusions: Patients treated with surgery demonstrated clinically and statistically significant improvements in pain and HRQOL up to 1-year postsurgery. Treatment with radiotherapy alone resulted in improved pain scores, but these were not sustained beyond 3 months and HRQOL outcomes demonstrated nonsignificant changes over time. Within the SINS potentially unstable group, distinct clinical profiles were observed in patients treated with surgery or radiotherapy alone.
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http://dx.doi.org/10.1016/j.spinee.2020.10.017DOI Listing
March 2021

Testing the impact of discoplasty on the biomechanics of the intervertebral disc with simulated degeneration: An in vitro study.

Med Eng Phys 2020 10 30;84:51-59. Epub 2020 Jul 30.

Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Viale Risorgimento, 2, Bologna 40136, Italy. Electronic address:

Percutaneous Cement Discoplasty has recently been developed to relieve pain in highly degenerated intervertebral discs presenting a vacuum phenomenon in patients that cannot undergo major surgery. Little is currently known about the biomechanical effects of discoplasty. This study aimed at investigating the feasibility of modelling empty discs and subsequent discoplasty surgery and measuring their impact over the specimen geometry and mechanical behaviour. Ten porcine lumbar spine segments were tested in flexion, extension, and lateral bending under 5.4 Nm (with a 200 N compressive force and a 27 mm offset). Tests were performed in three conditions for each specimen: with intact disc, after nucleotomy and after discoplasty. A 3D Digital Image Correlation (DIC) system was used to measure the surface displacements and strains. The posterior disc height, range of motion (ROM), and stiffness were measured at the peak load. CT scans were performed to confirm that the cement distribution was acceptable. Discoplasty recovered the height loss caused by nucleotomy (p = 0.04) with respect to the intact condition, but it did not impact significantly either the ROM or the stiffness. The strains over the disc surface increased after nucleotomy, while discoplasty concentrated the strains on the endplates. In conclusion, this preliminary study has shown that discoplasty recovered the intervertebral posterior height, opening the neuroforamen as clinically observed, but it did not influence the spine mobility or stiffness. This study confirms that this in vitro approach can be used to investigate discoplasty.
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http://dx.doi.org/10.1016/j.medengphy.2020.07.024DOI Listing
October 2020

Expert's Comment concerning Grand Rounds Case entitled "Percutaneous cement discoplasty for the treatment of advanced degenerative disk disease in elderly patients" : (C. Sola, et al., Eur Spine J; 2018: DOI 10.1007/s00586-018-5547-7).

Authors:
Aron Lazary

Eur Spine J 2021 08 19;30(8):2209-2210. Epub 2020 Aug 19.

National Center for Spinal Disorders, Department of Spine Surgery, Semmelweis University, Kiralyhago u. 1-3, Budapest, 1125, Hungary.

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http://dx.doi.org/10.1007/s00586-020-06568-4DOI Listing
August 2021

Outcome of group physical therapy treatment for non-specific low back pain patients can be predicted with the cross-culturally adapted and validated Hungarian version STarT back screening tool.

Disabil Rehabil 2020 Jul 31:1-9. Epub 2020 Jul 31.

Department of Research and Development, National Center for Spinal Disorders, Budapest, Hungary.

Purpose: The STarT Back Tool was developed to identify the specific modifiable prognostic factors for non-specific low back pain and to classify the patients into risk groups; low, medium and high risk of chronicity. Applied therapeutic approaches often involve group physical therapy. The aim of this study was the cross-cultural adaptation and validation of the Hungarian version of the STarT Back Tool and to investigate the predictive ability for global treatment outcome.

Materials And Methods: A prospective cohort study ( = 133) was carried out involving non-specific low back pain patients. Internal consistency, construct validity, reliability and prognostic discriminative ability have been investigated. After 3 months of treatment global outcome was evaluated.

Results: A 2-factor structure was found, with moderate internal consistency (Cronbach α = 0.89 for the total and psychosocial subscale 0.62). Between the Hungarian STarT Back Tool, the Oswestry Disability Index, leg pain, low back pain, Tampa Scale for Kinesiophobia, Fear Avoidance Beliefs Questionnaire and the physical subscale of the quality of life questionnaire, significant good to excellent- correlation was found ( > 0.41). The test-retest analysis showed excellent reliability (Intraclass Correlation Coefficient = 0.93) with standard error measurement being 0.49 (minimal detectable change = 1.37). The Area Under the Curve for baseline STarT Back Tool scores was 0.7 and 0.8 for global treatment outcome and distress, respectively. The Area Under the Curve for global treatment outcome versus STarT risk groups proved to be 0.76 representing adequate discriminative ability.

Conclusion: The successful cross-cultural adaptation was followed by the validity analysis and as a result the Hungarian version of the STarT Back Tool proved to be a reliable and valid tool in the identification of risk groups of chronicity for patients with low back pain. Patients allocated to the high-risk group were more likely experiencing poor outcome at 3 months follow up, thus it can be used to predict outcome if treated with group physical therapy.Implication for rehabilitationLow back pain is a multifactorial disease where physical and psychosocial risk factors play a role in the development and prognosis of the disease.The STarT-H can be considered as a reliable, valid measurement tool in the identification of risk groups of chronicity for patients with low back pain.Clinical relevance of the STarT-H is that it can be used to stratify patients into risk groups of chronicity in different Hungarian speaking healthcare settings.According to our findings the STarT-H can also be applied to predict global treatment outcome in low back pain patients if treated with group physical therapy.
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http://dx.doi.org/10.1080/09638288.2020.1799248DOI Listing
July 2020

Global Treatment Outcome after Surgical Site Infection in Elective Degenerative Lumbar Spinal Operations.

Surg Infect (Larchmt) 2021 Mar 23;22(2):193-199. Epub 2020 Apr 23.

National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.

Surgical site infection (SSI) is a serious complication after routine lumbar spinal operations, and its effect on global treatment outcome (GTO) is less reported. The aim of the current study was to measure the impact of SSI on outcome, which was evaluated with patient reported outcome measures (PROMs) and patients' subjective judgment (GTO). A total of 910 patients underwent primary a single- or two-level lumbar decompression or instrumented fusion surgical procedure. Patients completed Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measurement Index (COMI) at baseline and at two-year follow-up. The rate of improvement in PROMs was measured for the total cohort and the group of patients with SSI. Patients evaluated GTO on a five-point Likert scale. This study was approved by the Scientific and Research Ethics Committee of the Medical Research Council (number: 29970-3/2015/EKU) and the Institutional Review Board. Regardless of the presence of SSI, significant improvement was measured in all PROMs without any difference in the rate of change between the clinical subgroups (non-SSI vs. SSI, dODI: p = 0.370, dCOMI: p = 0.383, dVAS: p = 0.793). In the total cohort, 87.3% of patients reported good outcome (N% = 87.3%). After an SSI, however, more patients (25.7%) reported poor outcome compared with those without the complication (chi-square test: value = 5.66; df = 1; p = 0.017; odds ratio = 2.49). Patients with successfully treated SSI can expect as good objective clinical result as patients without SSI while the subjective treatment outcome can be worse. The GTO could also be improved in complicated cases, however, with more extensive peri-operative patient education and information considering the patients' expectations, too.
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http://dx.doi.org/10.1089/sur.2019.344DOI Listing
March 2021

Surgical or Radiation Therapy for the Treatment of Cervical Spine Metastases: Results From the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) Cohort.

Global Spine J 2020 Feb 31;10(1):21-29. Epub 2019 Mar 31.

University of British Columbia, Vancouver, British Columbia, Canada.

Study Design: Ambispective cohort study design.

Objectives: Cervical spine metastases have distinct clinical considerations. The aim of this study was to determine the impact of surgical intervention (± radiotherapy) or radiotherapy alone on health-related quality of life (HRQOL) outcomes in patients treated for cervical metastatic spine tumours.

Methods: Patients treated with surgery and/or radiotherapy for cervical spine metastases were identified from the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) international multicentre prospective observational study. Demographic, diagnostic, treatment, and HRQOL (numerical rating scale [NRS] pain, EQ-5D (3L), SF-36v2, and SOSGOQ) measures were prospectively collected at baseline, 6 weeks, 3 months, and 6 months postintervention.

Results: Fifty-five patients treated for cervical metastases were identified: 38 underwent surgery ± radiation and 17 received radiation alone. Surgically treated patients had higher mean spinal instability neoplastic scores compared with the radiation-alone group (13.0 vs 8.0, < .001) and higher NRS pain scores and lower HRQOL scores compared to the radiation alone group ( < .05). From baseline to 6 months posttreatment, surgically treated patients demonstrated statistically significant improvements in NRS pain, EQ-5D (5L), and SOSGOQ2.0 scores compared with nonsignificant improvements in the radiotherapy alone group.

Conclusions: Surgically treated cervical metastases patients presented with higher levels of instability, worse baseline pain and HRQOL scores compared with patients who underwent radiotherapy alone. Significant improvements in pain and HRQOL were noted for those patients who received surgical intervention. Limited or no improvements were found in those treated with radiotherapy alone.
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http://dx.doi.org/10.1177/2192568219839407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6963359PMC
February 2020

Correction to: Association of vitamin D receptor gene polymorphisms with disc degeneration.

Eur Spine J 2020 Mar;29(3):648

National Center for Spinal Disorders, Kiralyhago Street 1, Budapest, 1126, Hungary.

Unfortunately, the following reference was missed out in the original publication.
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http://dx.doi.org/10.1007/s00586-019-06284-8DOI Listing
March 2020

Geometrical accuracy evaluation of an affordable 3D printing technology for spine physical models.

J Clin Neurosci 2020 Feb 3;72:438-446. Epub 2020 Jan 3.

National Center for Spinal Disorders, Királyhágó u. 1-3, H-1126 Budapest, Hungary.

Objective: The aim of the study is to develop a workflow to establish geometrical quality criteria for 3D printed anatomical models as a guidance for selecting the most suitable 3D printing technologies available in a clinical environment.

Methods: We defined the 3D geometry of a 25-year-old male patient's L4 vertebra and the geometry was then printed using two technologies, which differ in printing resolution and affordability: Fused Deposition Modelling (FDM) and Digital Light Processing (DLP). In order to measure geometrical accuracy, the 3D scans of two physical models were compared to the virtual input model. To compare surface qualities of these printing technologies we determined surface roughness for two regions of interest. Finally, we present our experience in the clinical application of a physical model in a congenital deformity case.

Results: The analysis of the distribution of the modified Hausdorff distance values along the vertebral surface meshes (99% of values <1 mm) of the 3D printed models provides evidence for high printing accuracy in both printing techniques. Our results demonstrate that the surface qualities, measured by roughness are adequate (~99% of values <0.1 mm) for both physical models. Finally, we implemented the FDM physical model for surgical planning.

Conclusion: We present a workflow capable of determining the quality of 3D printed models and the application of a high quality and affordable 3D printed spine physical model in the pre operative planning. As a result of the visual guidance provided by the physical model, we were able to define the optimal trajectory of the screw insertion during surgery.
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http://dx.doi.org/10.1016/j.jocn.2019.12.027DOI Listing
February 2020

Association of vitamin D receptor gene polymorphisms with disc degeneration.

Eur Spine J 2020 03 25;29(3):596-604. Epub 2019 Nov 25.

National Center for Spinal Disorders, Kiralyhago Street 1, Budapest, 1126, Hungary.

Purpose: Numerous candidate genes and single-nucleotide polymorphisms (SNPs) have been identified in the background of lumbar disc degeneration (LDD). However, in most of these underpowered studies, definitions of LDD are inconsistent; moreover, many of the findings have not been replicated and are contradictory. Our aim was to characterize LDD by well-defined phenotypes and possible endophenotypes and analyse the association between these and candidate vitamin D receptor (VDR) gene polymorphisms on a large (N = 1426) dataset.

Methods: Seven candidate VDR SNPs were genotyped. Individual association, haplotype and gene-gene interaction analyses were performed. All degenerative endophenotypes were significantly associated with one or more candidate VDR gene variants.

Results: Haplotype analyses confirmed the association between the 3'-end VDR variants (BsmI, ApaI, TaqI) and Modic changes as well as the relationship of 5'-end variants (Cdx2, A1012G) with endplate defects. We also found significant interactions between the 3'- and 5'-end regulatory regions and endplate defects. Based on our results, VDR and its gene variants are highly associated with specific degenerative LDD endophenotypes.

Conclusion: Understanding relationships between phenotype and gene variants is crucial for describing the pathways leading to the multifactorial, polygenic degeneration process and LDD-related conditions. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-06215-7DOI Listing
March 2020

Metastatic Spine Disease: Should Patients With Short Life Expectancy Be Denied Surgical Care? An International Retrospective Cohort Study.

Neurosurgery 2020 08;87(2):303-311

Division of Spine Surgery, Department of Orthopaedics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada.

Background: Despite our inability to accurately predict survival in many cancer patients, a life expectancy of at least 3 mo is historically necessary to be considered for surgical treatment of spinal metastases.

Objective: To compare health-related quality of life (HRQOL) in patients surviving <3 mo after surgical treatment to patients surviving >3 mo to assess the validity of this inclusion criteria.

Methods: Patients who underwent surgery for spinal metastases between August 2013 and May 2017 were retrospectively identified from an international cohort study. HRQOL was evaluated using generic and disease-specific outcome tools at baseline and at 6 and 12 wk postsurgery. The primary outcome was the HRQOL at 6 wk post-treatment measured by the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

Results: A total of 253 patients were included: 40 patients died within the first 3 mo after surgery and 213 patients survived more than 3 mo. Patients surviving <3 mo after surgery presented with lower baseline performance status. Adjusted analyses for baseline performance status did not reveal a significant difference in HRQOL between both groups at 6 wk post-treatment. No significant difference in patient satisfaction at 6 wk with regard to their treatment could be detected between both groups.

Conclusion: When controlled for baseline performance status, quality of life 6 wk after surgery for spinal metastasis is independent of survival. To optimize improvement in HRQOL for this patient population, baseline performance status should take priority over expected survival in the surgical decision-making process.
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http://dx.doi.org/10.1093/neuros/nyz472DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360875PMC
August 2020

Attitude of spine surgeons towards the application of 3D technologies - a survey of AOSpine members.

Ideggyogy Sz 2019 Jul;72(7-8):227-235

National Center for Spinal Disorders, Budapest.

Background And Purpose: 3D technologies (3D virtual and physical model, 3D printing, computer aided engineering, finite element analysis based simulations) play an important role in personalized spine surgery. Objective - In collaboration with AOSpine a global, online survey-based study was performed in order to determine the acceptance rate and the factors which stand against the wider spread of 3D technologies.

Methods: A survey containing 21 questions was developed and divided into five pages, every page corresponding to one chapter. Our analysis is based on the responses of 282 spine surgeons from 57 countries. To interpret our results in a global context, we used the Human Development Index of the respondent's countries in comparisons.

Results: Significant difference between the AOSpine regions (p ≤ 0.05) was found, with the highest acceptance in Asia-Pacific region. There was no significant difference in acceptance score according to the field of spine surgery, or the surgical experience in years (p=0.77, and p=0.19). In the case of public practice, we found significantly higher acceptance compared to private and mixed (public and private) surgical practice (p ≤ 0.05). The acceptance of the technology varied based on the respondent's resident country's Human Development Index and was significantly different between "Medium" vs "Very high" (p = 0.0005) and "High" vs "Very high" (p=0.019) category. Significant positive correlation was found between the acceptance score and the HDI score (Spearman test, ρ = 0.37, p = 0.007). The main limitation factor was identified as the lack of information.

Conclusion: There is high interest among spine surgeons towards the incorporation of 3D technologies into the clinical practice. Education, the healthcare system, and the economic environment plays a major role in acceptance. Our results provide the basis of a strategy to promote the application of 3D technologies.
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http://dx.doi.org/10.18071/isz.72.0227DOI Listing
July 2019

Patient satisfaction with treatment outcomes after surgery and/or radiotherapy for spinal metastases.

Cancer 2019 12 6;125(23):4269-4277. Epub 2019 Sep 6.

Division of Spine Surgery, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada.

Background: Patient satisfaction is infrequently investigated despite its importance in assessing efficacy and patient comprehension. The purpose of this study was to investigate patient satisfaction with treatment outcomes after surgery and/or radiotherapy for spinal metastases and to evaluate how health-related quality of life (HRQOL) is related to patient satisfaction.

Methods: Patients with spinal metastases treated with surgery and/or radiotherapy were enrolled in a prospective, international, observational study. Demographic, histologic, treatment, and HRQOL data were collected. HRQOL was evaluated with the Numeric Rating Scale pain score, the 3-level version of the EuroQol 5-Dimension (EQ-5D-3L) instrument, and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0). Patient satisfaction was derived from the SOSGOQ2.0 at 6, 12, and 26 weeks after treatment. Patients were classified as satisfied, neutral, or dissatisfied.

Results: Twelve weeks after treatment, 183 of the surgically treated patients (84%) were satisfied, and only 11 (5%) were dissatisfied; in contrast, 101 of the patients treated with radiotherapy alone (77%) were satisfied, and only 7 (5%) were dissatisfied. Significant improvements in pain, physical function, mental health, social function, leg function, and EQ-5D were associated with satisfaction after surgery. Satisfaction after radiotherapy was associated with significant improvements in pain, mental health, and overall SOSGOQ2.0 scores. Dissatisfaction after treatment was associated with lower baseline values for leg strength and lower social functioning scores for surgically treated patients and with lower social functioning scores and being single for patients treated with radiotherapy.

Conclusions: High levels of satisfaction with treatment outcomes are observed after surgery and/or radiotherapy for spinal metastases. Posttreatment satisfaction is associated with significant improvements in pain and different dimensions of HRQOL.
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http://dx.doi.org/10.1002/cncr.32465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900159PMC
December 2019

Association of neurologic deficits with surgical outcomes and health-related quality of life after treatment for metastatic epidural spinal cord compression.

Cancer 2019 12 13;125(23):4224-4231. Epub 2019 Aug 13.

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: A critical knowledge gap exists regarding the impact of neurologic deficits on surgical outcomes and health-related quality of life (HRQOL) for patients surgically treated for metastatic epidural spinal cord compression (MESCC).

Methods: This prospective, multicenter and international study analyzed the impact of the neurologic status on functional status, HRQOL, and postoperative survival. The collected data included the patient demographics, overall survival, American Spinal Injury Association (ASIA) impairment scale, Spinal Instability Neoplastic Score, treatment details and complications and HRQOL measures, including version 2 of the 36-Item Short Form Health Survey (SF-36v2) and version 2.0 of the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0).

Results: A total of 239 patients surgically treated for spinal metastases were included. Six weeks after treatment, 99 of the 108 patients with a preoperative ASIA grade of E remained stable, 8 deteriorated to ASIA D, and 1 deteriorated to ASIA A. Of 55 patients with ASIA D, 27 improved to ASIA E, 27 remained stable and 1 deteriorated to ASIA C. Of 11 patients with ASIA A to C, 2 improved to ASIA E, 4 improved to ASIA D, and 5 remained stable. At the 6- and 12-week follow-up, better ASIA scores were associated with better scores on multiple SF-36v2 and SOSGOQ items. Postoperatively, patients with ASIA grades of A to D were more likely to have urinary tract infections and wound complications. Patients with a baseline ASIA grade of E or D survived significantly longer.

Conclusions: Patients with neurologic deficits due to MESCC have worse HRQOL and decreased overall survival. Nevertheless, surgery can result in stabilization or improvement of neurologic function which may translate into better HRQOL. Postoperative care and follow-up are challenging for patients with neurologic deficits because they experience more complications.
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http://dx.doi.org/10.1002/cncr.32420DOI Listing
December 2019

Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice.

Global Spine J 2019 May 8;9(1 Suppl):98S-107S. Epub 2019 May 8.

Memorial Sloan-Kettering Cancer Center, New York, NY.

Study Design: Literature review.

Objective: To provide an overview of the recent advances in spinal oncology, emphasizing the key role of the surgeon in the treatment of patients with spinal metastatic tumors.

Methods: Literature review.

Results: Therapeutic advances led to longer survival times among cancer patients, placing significant emphasis on durable local control, optimization of quality of life, and daily function for patients with spinal metastatic tumors. Recent integration of modern diagnostic tools, precision oncologic treatment, and widespread use of new technologies has transformed the treatment of spinal metastases. Currently, multidisciplinary spinal oncology teams include spinal surgeons, radiation and medical oncologists, pain and rehabilitation specialists, and interventional radiologists. Consistent use of common language facilitates communication, definition of treatment indications and outcomes, alongside comparative clinical research. The main parameters used to characterize patients with spinal metastases include functional status and health-related quality of life, the spinal instability neoplastic score, the epidural spinal cord compression scale, tumor histology, and genomic profile.

Conclusions: Stereotactic body radiotherapy revolutionized spinal oncology through delivery of durable local tumor control regardless of tumor histology. Currently, the major surgical indications include mechanical instability and high-grade spinal cord compression, when applicable, with surgery providing notable improvement in the quality of life and functional status for appropriately selected patients. Surgical trends include less invasive surgery with emphasis on durable local control and spinal stabilization.
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http://dx.doi.org/10.1177/2192568219830323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512191PMC
May 2019

Primary Bone Tumor of the Spine-An Evolving Field: What a General Spine Surgeon Should Know.

Global Spine J 2019 May 8;9(1 Suppl):108S-116S. Epub 2019 May 8.

University of British Columbia, Vancouver, British Columbia, Canada.

Study Design: A narrative review of the literature.

Objective: This article reviews the general principles of treatment and investigation for primary bone tumors of the spine. Furthermore, it explores the emerging alternatives.

Methods: A review was performed using Medline, Embase, and Cochrane databases.

Results: Primary bone tumors of the spine are rare entities that general spine surgeons may encounter only a few times in their career. The treatment algorithm of these complex tumors is filled with nuances and is evolving constantly. For these reasons, patients should be referred to experienced tertiary or quaternary centers who can offer a comprehensive multidisciplinary approach. For most malignant spinal bone tumors, surgery remains the cornerstone of treatment. Respecting oncologic principles has been associated with improved survival and decreased local recurrence in multiple settings. However, even in experienced centers, these surgeries carry a significant risk of adverse events and possible long-term neurologic impairment. The associated morbidity of these procedures and the challenges of local recurrence have encouraged professionals caring for these patients to explore alternatives or adjuncts to surgical treatment.

Conclusions: Over the past few years, several advances have occurred in medical oncology, radiation oncology and interventional radiology, changing the treatment paradigm for some tumors. Other advances still need to be refined before being applied in a clinical setting.
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http://dx.doi.org/10.1177/2192568219828727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512194PMC
May 2019

Indirect foraminal decompression and improvement in the lumbar alignment after percutaneous cement discoplasty.

Eur Spine J 2019 06 20;28(6):1441-1447. Epub 2019 Apr 20.

National Center for Spinal Disorders, Buda Health Center, Királyhágó St. 1-3, Budapest, 1126, Hungary.

Purpose: Percutaneous cement discoplasty (PCD) is a minimally invasive surgical procedure, that can provide a segmental stabilizing and indirect decompression effect in case of severely degenerated discs characterized by vacuum phenomenon. The objective of this study was to evaluate the effects of PCD on spinopelvic radiological parameters and their associations with the clinical outcome.

Methods: Retrospective analysis of prospectively collected dataset of 28 patients (112 lumbar segments) who underwent single- or multilevel PCD was performed. Spinopelvic, intrasegmental and intersegmental parameters were measured on lumbar X-rays pre-, postoperatively and 6 months after the surgery. Correlations between radiological parameters and clinical outcome data were determined.

Results: Sacral slope significantly increased (p < .001), and pelvic tilt (p < .05) was decreased after the PCD procedure. Segmental and total lordosis (p < .05, p < .05) disc and foraminal height showed significantly increase (p < .001, p < .001) after procedure. Pain and disability (ODI) significantly decreased due to PCD. An association was found between postoperative increase in SS and improvement in ODI (r = 0.39, p < .05). The change in low back pain was correlated with segmental scoliosis correction (p < .001). Moderate correlation was detected between the increase in disc height and ODI (p < .05) as well as leg pain (p < .01).

Conclusion: PCD is an effective minimally invasive technique to treat axial pain and disability related to severe lumbar disc degeneration. Our study shows that an improvement in lumbar alignment and a significant indirect foraminal decompression could be achieved with the procedure. These changes can significantly contribute to the pain relief and increase in the patients' functional capacity. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-05966-7DOI Listing
June 2019

Prognostic significance of human telomerase reverse transcriptase promoter region mutations C228T and C250T for overall survival in spinal chordomas.

Neuro Oncol 2019 08;21(8):1005-1015

Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Spinal chordomas, a subtype of primary spinal column malignancies (PSCM), are rare tumors with poor prognosis, and we have limited understanding of the molecular drivers of neoplasia.

Methods: Study design was a retrospective review of prospectively collected data with cross-sectional survival. Archived paraffin embedded pathologic specimens were collected for 133 patients from 6 centers within Europe and North America between 1987 and 2012. Tumor DNA was extracted and the human telomerase reverse transcriptase (hTERT) promoter was sequenced. The hTERT mutational status was correlated with overall survival (OS) and time to first local recurrence.

Results: Ninety-two chordomas, 26 chondrosarcomas, 7 osteosarcomas, 3 Ewing's sarcomas, and 5 other malignant spinal tumors were analyzed. Median OS following surgery was 5.8 years (95% CI: 4.6 to 6.9) and median time to first local recurrence was 3.9 years (95% CI: 2.5 to 6.7). Eight chordomas, 2 chondrosarcomas, 1 Ewing's sarcoma, and 1 other malignant spinal tumor harbored either a C228T or C250T mutation in the hTERT promoter. In the overall cohort, all patients with hTERT mutation were alive at 10 years postoperative with a median OS of 5.1 years (95% CI: 4.5 to 6.6) (P = 0.03). hTERT promoter mutation was observed in 8.7% of spinal chordomas, and 100% of chordoma patients harboring the mutation were alive at 10 years postoperative compared with 67% patients without the mutation (P = 0.05).

Conclusions: We report for the first time that hTERT promoter mutations C228T and C250T are present in approximately 8.7% of spinal chordomas. The presence of hTERT mutations conferred a survival benefit and could potentially be a valuable positive prognostic molecular marker in spinal chordomas.
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http://dx.doi.org/10.1093/neuonc/noz066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682209PMC
August 2019

Current treatment strategy for newly diagnosed chordoma of the mobile spine and sacrum: results of an international survey.

J Neurosurg Spine 2018 10;30(1):119-125

19Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts.

OBJECTIVEThe purpose of this study was to investigate the spectrum of current treatment protocols for managing newly diagnosed chordoma of the mobile spine and sacrum.METHODSA survey on the treatment of spinal chordoma was distributed electronically to members of the AOSpine Knowledge Forum Tumor, including neurosurgeons, orthopedic surgeons, and radiation oncologists from North America, South America, Europe, Asia, and Australia. Survey participants were pre-identified clinicians from centers with expertise in the treatment of spinal tumors. The suvey responses were analyzed using descriptive statistics.RESULTSThirty-nine of 43 (91%) participants completed the survey. Most (80%) indicated that they favor en bloc resection without preoperative neoadjuvant radiation therapy (RT) when en bloc resection is feasible with acceptable morbidity. The main area of disagreement was with the role of postoperative RT, where 41% preferred giving RT only if positive margins were achieved and 38% preferred giving RT irrespective of margin status. When en bloc resection would result in significant morbidity, 33% preferred planned intralesional resection followed by RT, and 33% preferred giving neoadjuvant RT prior to surgery. In total, 8 treatment protocols were identified: 3 in which en bloc resection is feasible with acceptable morbidity and 5 in which en bloc resection would result in significant morbidity.CONCLUSIONSThe results confirm that there is treatment variability across centers worldwide for managing newly diagnosed chordoma of the mobile spine and sacrum. This information will be used to design an international prospective cohort study to determine the most appropriate treatment strategy for patients with spinal chordoma.
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http://dx.doi.org/10.3171/2018.6.SPINE18362DOI Listing
October 2018

Comparison of patient-specific computational models vs. clinical follow-up, for adjacent segment disc degeneration and bone remodelling after spinal fusion.

PLoS One 2018 30;13(8):e0200899. Epub 2018 Aug 30.

Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.

Spinal fusion is a standard surgical treatment for patients suffering from low back pain attributed to disc degeneration. However, results are somewhat variable and unpredictable. With fusion the kinematic behaviour of the spine is altered. Fusion and/or stabilizing implants carrying considerable load and prevent rotation of the fused segments. Associated with these changes, a risk for accelerated disc degeneration at the adjacent levels to fusion has been demonstrated. However, there is yet no method to predict the effect of fusion surgery on the adjacent tissue levels, i.e. bone and disc. The aim of this study was to develop a coupled and patient-specific mechanoregulated model to predict disc generation and changes in bone density after spinal fusion and to validate the results relative to patient follow-up data. To do so, a multiscale disc mechanoregulation adaptation framework was developed and coupled with a previously developed bone remodelling algorithm. This made it possible to determine extra cellular matrix changes in the intervertebral disc and bone density changes simultaneously based on changes in loading due to fusion surgery. It was shown that for 10 cases the predicted change in bone density and degeneration grade conforms reasonable well to clinical follow-up data. This approach helps us to understand the effect of surgical intervention on the adjacent tissue remodelling. Thereby, providing the first insight for a spine surgeon as to which patient could potentially be treated successfully by spinal fusion and in which patient has a high risk for adjacent tissue changes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200899PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116979PMC
January 2019

Risk factors of non-specific spinal pain in childhood.

Eur Spine J 2018 05 15;27(5):1119-1126. Epub 2018 Feb 15.

National Center for Spinal Disorders, Kiralyhago u. 1-3, Budapest, 1126, Hungary.

Purpose: Non-specific spinal pain can occur at all ages and current evidence suggests that pediatric non-specific spinal pain is predictive for adult spinal conditions. A 5-year long, prospective cohort study was conducted to identify the lifestyle and environmental factors leading to non-specific spinal pain in childhood.

Materials And Methods: Data were collected from school children aged 7-16 years, who were randomly selected from three different geographic regions in Hungary. The risk factors were measured with a newly developed patient-reported questionnaire (PRQ). The quality of the instrument was assessed by the reliability with the test-retest method. Test (N = 952) and validity (N = 897) datasets were randomly formed. Risk factors were identified with uni- and multivariate logistic regression models and the predictive performance of the final model was evaluated using the receiver operating characteristic (ROC) method.

Results: The final model was built up by seven risk factors for spinal pain for days; age > 12 years, learning or watching TV for more than 2 h/day, uncomfortable school-desk, sleeping problems, general discomfort and positive familiar medical history (χ = 101.07; df = 8; p < 0.001). The probabilistic performance was confirmed with ROC analysis on the test and validation cohorts (AUC = 0.76; 0.71). A simplified risk scoring system showed increasing possibility for non-specific spinal pain depending on the number of the identified risk factors (χ = 65.0; df = 4; p < 0.001).

Conclusion: Seven significant risk factors of non-specific spinal pain in childhood were identified using the new, easy to use and reliable PRQ which makes it possible to stratify the children according to their individual risk. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-018-5516-1DOI Listing
May 2018

[Change of paradigm in the surgical treatment of metastatic diseases of the bone. Part II. Treatment of spinal metastases].

Orv Hetil 2018 Feb;159(8):297-302

Országos Gerincgyógyászati Központ Budapest, Királyhágó u. 1-3., 1126.

The incidence of spinal metastases is constantly growing, but due to the advancements in oncologic treatment methods, the survival and the quality of life of the patients are persistently improving. Choosing the optimal treatment method is essential, and several factors should be considered: type of the primary tumor, segmental stability, the symptoms caused by the metastasis and the general condition of the patient. Using modern radiotherapeutic methods combined with minimally invasive surgical techniques (minimally invasive stabilization, separation surgery) in the majority of patients permits adequate local control with low complication rate. In our review, we describe the state-of-the-art, modern spinal metastasis treatment options based on the recently published evidence. Orv Hetil. 2018; 159(8): 297-302.
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http://dx.doi.org/10.1556/650.2018.30930DOI Listing
February 2018

Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine.

EFORT Open Rev 2017 Sep 1;2(9):372-381. Epub 2017 Sep 1.

National Center for Spinal Disorders, H-1126 Budapest, Királyhágó u.1., Hungary.

Oncological management of skeletal metastases has changed dramatically in the last few decades. A significant number of patients survive for many years with their metastases.Surgeons are more active and the technical repertoire is broader, from plates to intramedullary devices to (tumour) endoprostheses.The philosophy of treatment should be different in the case of a trauma-related fracture and a pathological fracture. A proper algorithm for establishing a diagnosis and evaluation of prognostic factors helps in planning the surgical intervention.The aim of palliative surgery is usually to eliminate pain and to allow the patient to regain his/her mobility as well as to improve the quality of life through minimally invasive techniques using life-long durable devices.In a selected group of patients with an oncologically controlled primary tumour site and a solitary bone metastasis with positive prognostic factors, which meet the criteria for radical excision (approximately 10% to 15% of the cases), a promising three to five years of survival may be achieved, especially in cases of metastases from breast and kidney cancer.Spinal metastases require meticulous evaluation because decisions on treatment mostly depend on the tumour type, segmental stability, the patient's symptoms and general state of health.Advanced radiotherapy combined with minimally invasive surgical techniques (minimally invasive stabilisation and separation surgery) provides durable local control with a low complication rate in a number of patients. Cite this article: 2017;2:372-381.
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http://dx.doi.org/10.1302/2058-5241.2.170006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644421PMC
September 2017
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