Publications by authors named "Daryl R Fourney"

92 Publications

Nerve root sedimentation sign on MRI: A triage screen for leg dominant symptoms?

Eur Spine J 2021 Jul 18. Epub 2021 Jul 18.

Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Purpose: Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain.

Methods: This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners).

Results: SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%).

Conclusions: Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00586-021-06919-9DOI Listing
July 2021

Commentary: Predicting Spinal Surgery Candidacy From Imaging Data Using Machine Learning.

Authors:
Daryl R Fourney

Neurosurgery 2021 06;89(1):E16-E17

Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyab127DOI Listing
June 2021

Development of a Patient-Oriented Intervention to Support Patient-Provider Conversations about Unnecessary Lower Back Pain Imaging.

Int J Environ Res Public Health 2021 03 9;18(5). Epub 2021 Mar 9.

Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada.

Background: despite the efforts of multiple stakeholders to promote appropriate care throughout the healthcare system, studies show that two out of three lower back pain (LBP) patients expect to receive imaging. We used the Choosing Wisely Canada patient-oriented framework, prioritizing patient engagement, to develop an intervention that addresses lower back pain imaging overuse.

Methods: to develop this intervention, we collaborated with a multidisciplinary advisory team, including two patient partners with lower back pain, researchers, clinicians, healthcare administrators, and the Choosing Wisely Canada lead for Saskatchewan. For this qualitative study, data were collected through two advisory team meetings, two individual interviews with lower back pain patient partners, and three focus groups with lower back pain patient participants. A lower back pain prescription pad was developed as an outcome of these consultations.

Results: participants reported a lack of interactive and informative communication was a significant barrier to receiving appropriate care. The most cited content information for inclusion in this intervention was treatments known to work, including physical activity, useful equipment, and reliable sources of educational material. Participants also suggested it was important that benefits and risks of imaging were explained on the pad. Three key themes derived from the data were also used to guide development of the intervention: (a) the role of imaging in LBP diagnosis; (b) the impact of the patient-physician relationship on LBP diagnosis and treatment; and (c) the lack of patient awareness of Choosing Wisely Canada and their recommendations.

Conclusions: the lower back pain patient-developed prescription pad may help patients and clinicians engage in informed conversations and shared decision making that could support reduce unnecessary lower back pain imaging.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijerph18052786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967489PMC
March 2021

A Randomized Controlled Trial of Local Delivery of a Rho Inhibitor (VX-210) in Patients with Acute Traumatic Cervical Spinal Cord Injury.

J Neurotrauma 2021 Aug 1;38(15):2065-2072. Epub 2021 Mar 1.

BioAxone BioSciences, Inc, Boston, Massachusetts, USA.

Acute traumatic spinal cord injury (SCI) can result in severe, lifelong neurological deficits. After SCI, Rho activation contributes to collapse of axonal growth cones, failure of axonal regeneration, and neuronal loss. This randomized, double-blind, placebo-controlled phase 2b/3 study evaluated the efficacy and safety of Rho inhibitor VX-210 (9 mg) in patients after acute traumatic cervical SCI. The study enrolled patients 14-75 years of age with acute traumatic cervical SCIs, C4-C7 (motor level) on each side, and American Spinal Injury Association Impairment Scale (AIS) Grade A or B who had spinal decompression/stabilization surgery commencing within 72 h after injury. Patients were randomized 1:1 with stratification by age (<30 vs. ≥30 years) and AIS grade (A vs. B with sacral pinprick preservation vs. B without sacral pinprick preservation). A single dose of VX-210 or placebo in fibrin sealant was administered topically onto the dura over the site of injury during decompression/stabilization surgery. Patients were evaluated for medical, neurological, and functional changes, and serum was collected for pharmacokinetics and immunological analyses. Patients were followed up for up to 12 months after treatment. A planned interim efficacy-based futility analysis was conducted after ∼33% of patients were enrolled. The pre-defined futility stopping rule was met, and the study was therefore ended prematurely. In the final analysis, the primary efficacy end-point was not met, with no statistically significant difference in change from baseline in upper-extremity motor score at 6 months after treatment between the VX-210 (9-mg) and placebo groups. This work opens the door to further improvements in the design and conduct of clinical trials in acute SCI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2020.7096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8309435PMC
August 2021

Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial.

Lancet Neurol 2021 02 22;20(2):98-106. Epub 2020 Dec 22.

Department of Health Services, University of Washington, Seattle, WA, USA.

Background: Degenerative cervical myelopathy represents the most common form of non-traumatic spinal cord injury. This trial investigated whether riluzole enhances outcomes in patients undergoing decompression surgery for degenerative cervical myelopathy.

Methods: This multicentre, double-blind, placebo-controlled, randomised, phase 3 trial was done at 16 university-affiliated centres in Canada and the USA. Patients with moderate-to-severe degenerative cervical myelopathy aged 18-80 years, who had a modified Japanese Orthopaedic Association (mJOA) score of 8-14, were eligible. Patients were randomly assigned (1:1) to receive either oral riluzole (50 mg twice a day for 14 days before surgery and then for 28 days after surgery) or placebo. Randomisation was done using permuted blocks stratified by study site. Patients, physicians, and outcome assessors remained masked to treatment group allocation. The primary endpoint was change in mJOA score from baseline to 6 months in the intention-to-treat (ITT) population, defined as all individuals who underwent randomisation and surgical decompression. Adverse events were analysed in the modified intention-to-treat (mITT) population, defined as all patients who underwent randomisation, including those who did not ultimately undergo surgical decompression. This study is registered with ClinicalTrials.gov, NCT01257828.

Findings: From Jan 31, 2012, to May 16, 2017, 408 patients were screened. Of those screened, 300 were eligible (mITT population); 290 patients underwent decompression surgery (ITT population) and received either riluzole (n=141) or placebo (n=149). There was no difference between the riluzole and placebo groups in the primary endpoint of change in mJOA score at 6-month follow-up: 2·45 points (95% CI 2·08 to 2·82 points) versus 2·83 points (2·47 to 3·19), difference -0·38 points (-0·90 to 0·13; p=0·14). The most common adverse events were neck or arm or shoulder pain, arm paraesthesia, dysphagia, and worsening of myelopathy. There were 43 serious adverse events in 33 (22%) of 147 patients in the riluzole group and 34 serious adverse events in 29 (19%) of 153 patients in the placebo group. The most frequent severe adverse events were osteoarthrosis of non-spinal joints, worsening of myelopathy, and wound complications.

Interpretation: In this trial, adjuvant treatment for 6 weeks perioperatively with riluzole did not improve functional recovery beyond decompressive surgery in patients with moderate-to-severe degenerative cervical myelopathy. Whether riluzole has other benefits in this patient population merits further study.

Funding: AOSpine North America.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1474-4422(20)30407-5DOI Listing
February 2021

Does a Multidisciplinary Triage Pathway Facilitate Better Outcomes After Spine Surgery?

Spine (Phila Pa 1976) 2021 Mar;46(5):322-328

Division of Neurosurgery, University of Saskatchewan, Saskatchewan, Canada.

Study Design: Single-center prospective non-randomized matched cohort comparison.

Objective: To compare elective lumbar spine surgery outcomes for cases triaged through a multidisciplinary spine pathway versus conventional referral processes.

Summary Of Background Data: Many health care systems have facilitated low back pain (LBP) guidelines into primary care practice by creating local or regional "pathways" with the goal of enhanced quality of care, improved patient satisfaction and optimal resource utilization, particularly for imaging and surgery. Few comparative outcomes exist for LBP pathways, particularly for surgical outcomes.

Methods: One-hundred-fifty patients (SSP group n = 75; conventional group n = 75) undergoing elective lumbar surgery for degenerative conditions between 2011 and 2016 were analyzed with 1-year follow-up. Patient self-reported outcomes included the Oswestry disability index (ODI), visual analogue pain scores (VAS) for back and leg, and EuroQol Group 5-Dimension self-report (EQ-5D). We also assessed baseline clinical features, indications for surgery, therapies received prior to surgery, type of surgery, wait times, and overall patient satisfaction.

Results: The groups had equivalent baseline demographics, body mass index, Saskatchewan Spine Pathway (SSP) classification of pain pattern, pain scores, functional scores, quality of life scores, indication for surgery, and type of surgery (instrumented or non-instrumented). There was no difference with respect to wait times to see the surgeon or for surgery. Wait time for magnetic resonance imaging (MRI) was significantly shorter for the SSP group (16.8 vs. 63.0 days, P < 0.001). Patients triaged through the SSP were significantly more likely to utilize multiple nonoperative treatment strategies prior to seeing the surgeon (P < 0.04). Patient satisfaction was significantly higher for SSP patients prior to surgical assessment (P = 0.03) but did not differ between groups after surgery.

Conclusion: The SSP facilitates significantly shorter wait times for MRI and promotes nonoperative treatment strategies. Preoperative patient satisfaction is significantly higher among SSP patients, but there were no significant differences in surgical outcomes.Level of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003785DOI Listing
March 2021

Considering Pedicle Screw Resistance in Electromyography of the Spine.

Oper Neurosurg (Hagerstown) 2020 12;20(1):69-73

Background: Evoked electromyographic (EMG) monitoring of pedicle screws has been shown to be an effective adjuvant to image guidance or direct visualization of pedicle screw placement. Electrical stimulation is delivered to the head of the screw at various intensities until a muscle potential is evoked. This practice is based on the fact that an intact pedicle effectively shields nerve roots from electrical stimulus. Several factors have been debated that may affect the interpretation of results; however, to the best of our knowledge, the electrical resistance of modern manufactured pedicle screws and stimulation devices has not been studied.

Objective: To determine if pedicle screw resistances affect triggered EMG.

Methods: Samples of the most commonly implanted pedicle screws in Canada were obtained, with diameters ranging from 4.5 to 7 mm. The resistance between the screw head and thread and core at the midpoint and tip of the screw was recorded using a Multimeter in accordance with IEEE standards. For screws with variable threads, the midpoint was considered the point at which the thread pitch changed.

Results: All screws had low impedances when tested at the point of the screw, but much higher when the cup is tested. The resistance of different manufactures' screws was significantly different, ranging from 0.514 to 2156 Ohms.

Conclusion: Despite differences in resistance, most screws had resistances in ranges that allow for triggered EMG pedicle integrity testing. Resistance from pedicle screws is an important consideration in EMG monitoring of the spine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ons/opaa271DOI Listing
December 2020

In-Hospital Mortality for the Elderly with Acute Traumatic Spinal Cord Injury.

J Neurotrauma 2020 11 26;37(21):2332-2342. Epub 2020 Aug 26.

Department of Orthopaedics, Vancouver Spine Surgery Institute, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

As the incidence of traumatic spinal cord injury (tSCI) in the elderly rises, clinicians are increasingly faced with difficult discussions regarding aggressiveness of management, likelihood of recovery, and survival. Our objective was to outline risk factors associated with in-hospital mortality in elderly surgical and non-surgical patients following tSCI and to determine those unlikely to have a favorable outcome. Data from elderly patients (≥ 65 years of age) in the Canadian Rick Hansen SCI Registry from 2004 to 2017 were analyzed using descriptive analysis. Survival and mortality groups in each of the surgical and non-surgical group were compared to explore factors associated with in-hospital mortality and their impact, using logistical regression. Of 1340 elderly patients, 1018 had surgical data with 826 having had surgery. In the surgical group, the median time to death post-injury was 30 days with 75% dying within 50 days compared with 7 days and 20 days, respectively, in the non-surgical group. Significant predictors for in-hospital mortality following surgery are age, comorbidities, neurological injury severity (American Spinal Injury Association [ASIA] Impairment Scale [AIS]), and ventilation status. The odds of dying 50 days post-surgery are six times higher for patients ≥77 years of age versus those 65-76 years of age, five times higher for those with AIS A versus those with AIS B/C/D, and seven times higher for those who are ventilator dependent. An expected probability of dying within 50 days post-surgery was determined using these results. In-hospital mortality in the elderly after tSCI is high. The trend with age and time to death and the significant predictors of mortality identified in this study can be used to inform clinical decision making and discussions with patients and their families.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2019.6912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585611PMC
November 2020

Traumatic spinal cord injuries among Aboriginal and non-Aboriginal populations of Saskatchewan: a prospective outcomes study.

Can J Surg 2020 06 4;63(3):E315-E320. Epub 2020 Jun 4.

From the Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Ahmed, Fourney); the Rick Hansen Institute, Vancouver, B.C. (Humphreys, Rivers); and the Waakebiness-Bryce Institute for Indigenous Health, University of Toronto, Toronto, Ont. (Jeffrey).

Background: People of Aboriginal (Indigenous) ancestry are more likely to experience traumatic spinal cord injury (TSCI) than other Canadians; however, outcome studies are limited. This study aims to compare Aboriginal and non-Aboriginal populations with acute TSCI with respect to preinjury baseline characteristics, injury severity, treatment, outcomes and length of stay.

Methods: This was a retrospective analysis of participants with a TSCI who were enrolled in the prospective Rick Hansen Spinal Cord Injury Registry (RHSCIR), Saskatoon site (Royal University Hospital), between Feb. 13, 2010, and Dec. 17, 2016. Demographic, injury and management data were assessed to identify any differences between the populations.

Results: Of the 159 patients admitted to Royal University Hospital with an acute TSCI during the study period, 62 provided consent and were included in the study. Of these, 21 self-identified as Aboriginal (33.9%) and 41 as non-Aboriginal (66.1%) on treatment intake forms. Compared with non-Aboriginal participants, Aboriginal participants were younger, had fewer medical comorbidities, had a similar severity of neurologic injury and had similar clinical outcomes. However, the time to discharge to the community was significantly longer for Aboriginal participants (median 104.0 v. 34.0 d, p = 0.016). Although 35% of non-Aboriginal participants were discharged home from the acute care site, no Aboriginal participants were transferred home directly.

Conclusion: This study suggests a need for better allocation of resources for transition to the community for Aboriginal people with a TSCI in Saskatchewan. We plan to assess outcomes from TSCI for Aboriginal people across Canada.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cjs.012819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829008PMC
June 2020

The Challenges of Renal Cell Carcinoma Metastatic to the Spine: A Systematic Review of Survival and Treatment.

Global Spine J 2018 Aug 20;8(5):517-526. Epub 2017 Nov 20.

The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Study Design: Systematic review.

Objectives: The objective of this systematic review was to answer 2 key questions: (1) What is the clinical presentation and probability of symptomatic improvement following treatment for patients with renal cell carcinoma (RCC) of the spine? (2) What is the overall survival of patients diagnosed with spinal metastases from RCC?

Methods: A literature review was performed to identify articles that reported on survival, clinical outcomes, and/or prognostic factors in the RCC population with spinal metastases from 1986 to 2016.

Results: Forty-eight articles (807 patients) were included. The Fuhrman Nuclear Grade has been significantly associated with survival in previous studies but was underpowered in the current study. The Memorial Sloan-Kettering Cancer Center Score (MSKCC/Motzer) was also underpowered in the current study. From the time of spinal metastasis, the mean and median survival for patients with previously diagnosed primary RCC was 8.75 and 11.7 months, respectively, whereas synchronously diagnosed patients (primary RCC and spinal metastasis) had a mean and median survival of 6.75 and 11 months, respectively. Patients with a "low" (0-8), "intermediate" (9-11), or "high" (12-15) revised Tokuhashi score at initial presentation had a median survival of 5.4, 11.7, and 32.9 months, respectively.

Conclusion: Patients with either a synchronous or latent diagnosis of RCC survived greater than 6 months from the time of presentation. Initial Furhman grade, Tokuhashi score, and MSKCC/Motzer can be useful tools in informing patient-specific prognosis for those with metastatic RCC of the spine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568217737777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6149047PMC
August 2018

The Effect of Tumor Neovasculature on Functional Magnetic Resonance Imaging Blood Oxygen Level-Dependent Activation.

World Neurosurg 2018 Jul 5;115:373-383. Epub 2018 May 5.

Division of Neurosurgery, Department of Surgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada; Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Electronic address:

Background: We report the case of a 40-year-old patient with a large, World Health Organization grade III oligodendroglioma in the left parietal lobe.

Case Description: Presurgical planning included functional magnetic resonance imaging (fMRI) localization of language, motor, and somatosensory processing. fMRI results for motor and somatosensory tasks revealed activation in perilesional regions near the surgical resection as well as deactivation in the tumor for the sensory task, suggesting decreased autoregulation in the region owing to the glioma. fMRI results showed left-hemisphere dominance for language and activation in perilesional regions for all 3 speech tasks (i.e., word reading, picture naming, and semantic questions). In addition, the results demonstrated that the high vascularity of the lesion altered the blood oxygen level-dependent function, resulting in false-positive and false-negative activation in the semantic questions and leg/foot rubbing task, respectively. Intraoperative direct cortical stimulation was conducted in the regions corresponding to fMRI activation while the patient performed motor, sensory, and language tasks and showed no loss of function. Follow-up fMRI revealed that there was no longer activation in the tumor or in perilesional regions, presumably owing to the resection of the vascularized tumor.

Conclusions: This case highlights the importance of presurgical fMRI to inform the neurosurgical approach and emphasizes the need for careful interpretation of fMRI data, especially in cases of malignant glioma, which can decrease autoregulation in surrounding regions, affecting fMRI blood oxygen level-dependent signal.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2018.04.200DOI Listing
July 2018

Expert's comment concerning Grand Rounds case entitled "Posterolateral cervical transpedicular corpectomy for the surgical management of metastatic tumor" by M.H. Pham et al. (Eur Spine J; 2018: DOI 10.1007/s00586-018-5466-7).

Authors:
Daryl R Fourney

Eur Spine J 2018 04 31;27(4):833-834. Epub 2018 Jan 31.

Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00586-018-5492-5DOI Listing
April 2018

Spinal Instability Neoplastic Score (SINS): Reliability Among Spine Fellows and Resident Physicians in Orthopedic Surgery and Neurosurgery.

Global Spine J 2017 Dec 20;7(8):744-748. Epub 2017 Jul 20.

University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Study Design: Reliability analysis.

Objectives: The Spinal Instability Neoplastic Score (SINS) was developed for assessing patients with spinal neoplasia. It identifies patients who may benefit from surgical consultation or intervention. It also acts as a prognostic tool for surgical decision making. Reliability of SINS has been established for spine surgeons, radiologists, and radiation oncologists, but not yet among spine surgery trainees. The purpose of our study is to determine the reliability of SINS among spine residents and fellows, and its role as an educational tool.

Methods: Twenty-three residents and 2 spine fellows independently scored 30 de-identified spine tumor cases on 2 occasions, at least 6 weeks apart. Intraclass correlation coefficient (ICC) measured interobserver and intraobserver agreement for total SINS scores. Fleiss's kappa and Cohen's kappa analysis evaluated interobserver and intraobserver agreement of 6 component subscores (location, pain, bone lesion quality, spinal alignment, vertebral body collapse, and posterolateral involvement of spinal elements).

Results: Total SINS scores showed near perfect interobserver (0.990) and intraobserver (0.907) agreement. Fleiss's kappa statistics revealed near perfect agreement for location; substantial for pain; moderate for alignment, vertebral body collapse, and posterolateral involvement; and fair for bone quality (0.948, 0.739, 0.427, 0.550, 0.435, and 0.382). Cohen's kappa statistics revealed near perfect agreement for location and pain, substantial for alignment and vertebral body collapse, and moderate for bone quality and posterolateral involvement (0.954, 0.814, 0.610, 0.671, 0.576, and 0.561, respectively).

Conclusions: The SINS is a reliable and valuable educational tool for spine fellows and residents learning to judge spinal instability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568217697691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721994PMC
December 2017

Systematic Review of the Outcomes of Surgical Treatment of Prostate Metastases to the Spine.

Global Spine J 2017 Aug 1;7(5):460-468. Epub 2017 Jun 1.

Johns Hopkins University, Baltimore, MD, USA.

Study Design: Systematic review.

Objective: Surgical decompression and reconstruction of symptomatic spinal metastases has improved the quality of life in cancer patients. However, most data has been collected on cohorts of patients with mixed tumor histopathology. We systematically reviewed the literature for prognostic factors specific to the surgical treatment of prostate metastases to the spine.

Methods: A systemic review of the literature was conducted to answer the following questions: Question 1. Describe the survival and functional outcomes of surgery or vertebral augmentation for prostate metastases to the spine. Question 2. Determine whether overall tumor burden, Gleason score, preoperative functional markers, and hormonal naivety favor operative intervention. Question 3. Establish whether clinical outcomes vary with the evolution of operative techniques.

Results: A total of 16 studies met the preset inclusion criteria. All included studies were retrospective series with a level of evidence of IV. Included studies consistently showed a large effect of hormone-naivety on overall survival. Additionally, studies consistently demonstrated an improvement in motor function and the ability to maintain/regain ambulation following surgery resulting in moderate strength of recommendation. All other parameters were of insufficient or low strength.

Conclusions: There is a dearth of literature regarding the surgical treatment of prostate metastases to the spine, which represents an opportunity for future research. Based on existing evidence, it appears that the surgical treatment of prostate metastases to the spine has consistently favorable results. While no consistent preoperative indicators favor nonoperative treatment, hormone-naivety and high Karnofsky performance scores have positive effects on survival and clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568217710911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5544163PMC
August 2017

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry.

Spine J 2018 01 1;18(1):88-98. Epub 2017 Jul 1.

Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, 818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada.

Background Context: Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

Purpose: The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.

Study Design/setting: This is a prospective observational study.

Patient Sample: The sample included participants with cervical SCI included in a prospective Canadian registry.

Outcome Measures: The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.

Methods: Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.

Results: Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.

Conclusions: We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2017.06.032DOI Listing
January 2018

Geomapping of Traumatic Spinal Cord Injury in Canada and Factors Related to Triage Pattern.

J Neurotrauma 2017 Oct 26;34(20):2856-2866. Epub 2017 Apr 26.

Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada.

Current research indicates that more than half of patients with traumatic spinal cord injury (tSCI) experience delays in transfer and receive surgery >24 h post-injury. The objectives of this study were to determine the geographic distribution of tSCI in Canada relative to specialized treatment facilities, to assess clinical and logistical factors at play for indirect admissions to those facilities, and to explore differences in current time to admission and simulated scenarios in an attempt to assess the potential impact of changes to triage protocols. This study included data from 876 patients with tSCI enrolled in the prospectively collected acute Rick Hansen Spinal Cord Injury Registry (RHSCIR) between January 1, 2010 and December 31, 2013 for whom there were data on the location of their injury. Patients transported directly to a RHSCIR acute facility were more likely to reach the facility within 1 h of injury, whereas those transported indirectly were more likely to arrive 7 h later. Considering the injuries occurring within 40 km of a RHSCIR acute facility ( = 323), 249 patients (77%) were directly and 74 (23%) were indirectly admitted. In the multivariate regression analysis, only older age and longer road distance remained significantly associated with being indirectly admitted to a RHSCIR facility. Compared with the current status, the median time to admission decreased by 20% (3.5 h) in the 100% direct admission scenario, and increased by 102% (8.9 h) in the 100% indirect admission scenario.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2016.4929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5652977PMC
October 2017

Adjacent Segment Pathology: Much to Do About How Much Is Due to What We Do.

Authors:
Daryl R Fourney

Can J Neurol Sci 2017 01;44(1):1-2

Division of NeurosurgeryUniversity of SaskatchewanSaskatoon,Saskatchewan,Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/cjn.2016.293DOI Listing
January 2017

The Spinal Instability Neoplastic Score: Impact on Oncologic Decision-Making.

Spine (Phila Pa 1976) 2016 Oct;41 Suppl 20:S231-S237

Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver General Hospital, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, Vancouver, BC, Canada.

Study Design: Systematic literature review.

Objective: To address the following questions in a systematic literature review: 1. How is spinal neoplastic instability defined or classified in the literature before and after the introduction of the Spinal Instability Neoplastic Score (SINS)? 2. How has SINS affected daily clinical practice? 3. Can SINS be used as a prognostic tool?

Summary Of Background Data: Spinal neoplastic-related instability was defined in 2010 and simultaneously SINS was introduced as a novel tool with criteria agreed upon by expert consensus to assess the degree of spinal stability.

Methods: PubMed, Embase, and clinical trial databases were searched with the key words "spinal neoplasm," "spinal instability," "spinal instability neoplastic score," and synonyms. Studies describing spinal neoplastic-related instability were eligible for inclusion. Primary outcomes included studies describing and/or defining neoplastic-related instability, SINS, and studies using SINS as a prognostic factor.

Results: The search identified 1414 articles, of which 51 met the inclusion criteria. No precise definition or validated assessment tool was used specific to spinal neoplastic-related instability prior to the introduction of SINS. Since the publication of SINS in 2010, the vast majority of the literature regarding spinal instability has used SINS to assess or describe instability. Twelve studies specifically investigated the prognostic value of SINS in patients who underwent radiotherapy or surgery.

Conclusion: No consensus could be determined regarding the definition, assessment, or reporting of neoplastic-related instability before introduction of SINS. Defining spinal neoplastic-related instability and the introduction of SINS have led to improved uniform reporting within the spinal neoplastic literature. Currently, the prognostic value of SINS is controversial.

Level Of Evidence: N/A.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000001822DOI Listing
October 2016

A Systematic Review of Clinical Outcomes and Prognostic Factors for Patients Undergoing Surgery for Spinal Metastases Secondary to Breast Cancer.

Global Spine J 2016 Aug 21;6(5):482-96. Epub 2015 Oct 21.

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, United States.

Study Design: Review of the literature.

Objective: Surgery and cement augmentation procedures are effective palliative treatment of symptomatic spinal metastases. Our objective is to systematically review the literature to describe the survival, prognostic factors, and clinical outcomes of surgery and cement augmentation procedures for breast cancer metastases to the spine.

Methods: We performed a literature review using PubMed to identify articles that reported outcomes and/or prognostic factors of the breast cancer patient population with spinal metastases treated with any surgical technique since 1990.

Results: The median postoperative survival for metastatic breast cancer was 21.7 months (8.2 to 36 months), the mean rate of any pain improvement was 92.9% (76 to 100%), the mean rate of neurologic improvement was 63.8% (53 to 100%), the mean rate of neurologic decline was 4.1% (0 to 8%), and the local tumor control rate was 92.6% (89 to 100%). Kyphoplasty studies reported a high rate of pain control in selected patients. Negative prognostic variables included hormonal (estrogen and progesterone) and human epidermal growth factor receptor 2 (HER2) receptor refractory tumor status, high degree of axillary lymph node involvement, and short disease-free interval (DFI). All other clinical or prognostic parameters were of low or insufficient strength.

Conclusion: With respect to clinical outcomes, surgery consistently yielded neurologic improvements in patients presenting with a deficit with a minimal risk of worsening; however, negative prognostic factors associated with shorter survival following surgery include estrogen receptor/progesterone receptor negativity, HER2 negativity, and a short DFI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0035-1564807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947406PMC
August 2016

Pre-Surgical Integration of fMRI and DTI of the Sensorimotor System in Transcortical Resection of a High-Grade Insular Astrocytoma.

Front Integr Neurosci 2016 11;10:15. Epub 2016 Mar 11.

Department of Psychology, University of SaskatchewanSaskatoon, SK, Canada; Department of Surgery, Division of Neurosurgery, Royal University HospitalSaskatoon, SK, Canada.

Herein we report on a patient with a WHO Grade III astrocytoma in the right insular region in close proximity to the internal capsule who underwent a right frontotemporal craniotomy. Total gross resection of insular gliomas remains surgically challenging based on the possibility of damage to the corticospinal tracts. However, maximizing the extent of resection has been shown to decrease future adverse outcomes. Thus, the goal of such surgeries should focus on maximizing extent of resection while minimizing possible adverse outcomes. In this case, pre-surgical planning included integration of functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI), to localize motor and sensory pathways. Novel fMRI tasks were individually developed for the patient to maximize both somatosensory and motor activation simultaneously in areas in close proximity to the tumor. Information obtained was used to optimize resection trajectory and extent, facilitating gross total resection of the astrocytoma. Across all three motor-sensory tasks administered, fMRI revealed an area of interest just superior and lateral to the astrocytoma. Further, DTI analyses showed displacement of the corona radiata around the superior dorsal surface of the astrocytoma, extending in the direction of the activation found using fMRI. Taking into account these results, a transcortical superior temporal gyrus surgical approach was chosen in order to avoid the area of interest identified by fMRI and DTI. Total gross resection was achieved and minor post-surgical motor and sensory deficits were temporary. This case highlights the utility of comprehensive pre-surgical planning, including fMRI and DTI, to maximize surgical outcomes on a case-by-case basis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fnint.2016.00015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4786563PMC
March 2016

Treatment of isolated cervical facet fractures: a systematic review.

J Neurosurg Spine 2016 Feb 30;24(2):347-354. Epub 2015 Oct 30.

Department of Neurosurgery, University of Maryland, Baltimore, Maryland.

OBJECT In this clinically based systematic review of cervical facet fractures, the authors' aim was to determine the optimal clinical care for patients with isolated fractures of the cervical facets through a systematic review. METHODS A systematic review of nonoperative and operative treatment methods of cervical facet fractures was performed. Reduction and stabilization treatments were compared, and analysis of postoperative outcomes was performed. MEDLINE and Scopus databases were used. This work was supported through support received from the Association for Collaborative Spine Research and AOSpine North America. RESULTS Eleven studies with 368 patients met the inclusion criteria. Forty-six patients had bilateral isolated cervical facet fractures and 322 had unilateral isolated cervical facet fractures. Closed reduction was successful in 56.4% (39 patients) and 63.8% (94 patients) of patients using a halo vest and Gardner-Wells tongs, respectively. Comparatively, open reduction was successful in 94.9% of patients (successful reduction of open to closed reduction OR 12.8 [95% CI 6.1-26.9], p < 0.0001); 183 patients underwent internal fixation, with an 87.2% success rate in maintaining anatomical alignment. When comparing the success of patients who underwent anterior versus posterior procedures, anterior approaches showed a 90.5% rate of maintenance of reduction, compared with a 75.6% rate for the posterior approach (anterior vs posterior OR 3.1 [95% CI 1.0-9.4], p = 0.05). CONCLUSIONS In comparison with nonoperative treatments, operative treatments provided a more successful outcome in terms of failure of treatment to maintain reduction for patients with cervical facet fractures. Operative treatment appears to provide superior results to the nonoperative treatments assessed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2015.6.SPINE141260DOI Listing
February 2016

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury.

CMAJ 2015 Sep 6;187(12):873-80. Epub 2015 Jul 6.

St. Michael's Hospital, University of Toronto Spine Program (Ahn), Toronto, Ont.; Western University (Bailey), London, Ont.; Rick Hansen Institute (Rivers, Noonan, Chen), Vancouver, BC; University of British Columbia (Noonan, Kwon, Townson, Dvorak), Vancouver, BC; The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa (Tsai), Ottawa, Ont.; University of Saskatchewan (Fourney), Saskatoon, Sask.; Horizon Health Network/Dalhousie University (Attabib), St. John, NB; Dalhousie University (Christie), Halifax, NS; Division of Neurosurgery and Spinal Program, University of Toronto (Fehlings), Toronto, Ont.; Sunnybrook Health Sciences Centre, University of Toronto (Finkelstein), Toronto, Ont.; University of Calgary Spine Program (Hurlbert), Calgary, Alta.; Hôpital du Sacré-Coeur de Montréal, Hôpital Ste-Justine, Université de Montréal (Parent), Montréal, Que.; Hamilton General Hospital, McMaster University (Drew), Hamilton, Ont.

Background: Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (≥ 70 yr) on treatment decisions and outcomes.

Methods: We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004-2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (< 70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre.

Results: Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p < 0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p < 0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p < 0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p < 0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22-1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19-0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p < 0.001).

Interpretation: We found chronological age to be a factor influencing treatment decisions but not at the 70-year age threshold that we had hypothesized. Older patients waited longer for surgery and had a substantially higher in-hospital mortality despite having less severe injuries than younger patients. Further research into the link between treatment delays and outcomes among older patients could inform surgical guideline development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.150085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562825PMC
September 2015

Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry.

J Neurotrauma 2015 Nov 17;32(21):1674-83. Epub 2015 Jul 17.

3 University of British Columbia , Vancouver, Canada .

In prior analyses of the effectiveness of methylprednisolone for the treatment of patients with acute traumatic spinal cord injuries (TSCIs), the prognostic importance of patients' neurological levels of injury and their baseline severity of impairment has not been considered. Our objective was to determine whether methylprednisolone improved motor recovery among participants in the Rick Hansen Spinal Cord Injury Registry (RHSCIR). We identified RHSCIR participants who received methylprednisolone according to the Second National Spinal Cord Injury Study (NASCIS-II) protocol and used propensity score matching to account for age, sex, time of neurological exam, varying neurological level of injury, and baseline severity of neurological impairment. We compared changes in total, upper extremity, and lower extremity motor scores using the Wilcoxon signed-rank test and performed sensitivity analyses using negative binomial regression. Forty-six patients received methylprednisolone and 1555 received no steroid treatment. There were no significant differences between matched participants for each of total (13.7 vs. 14.1, respectively; p=0.43), upper extremity (7.3 vs. 6.4; p=0.38), and lower extremity (6.5 vs. 7.7; p=0.40) motor recovery. This result was confirmed using a multivariate model and, as predicted, only cervical (C1-T1) rather than thoracolumbar (T2-L3) injury levels (p<0.01) and reduced baseline injury severity (American Spinal Injury Association [ASIA] Impairment Scale grades; p<0.01) were associated with greater motor score recovery. There was no in-hospital mortality in either group; however, the NASCIS-II methylprednisolone group had a significantly higher rate of total complications (61% vs. 36%; p=0.02) NASCIS-II methylprednisolone did not improve motor score recovery in RHSCIR patients with acute TSCIs in either the cervical or thoracic spine when the influence of anatomical level and severity of injury were included in the analysis. There was a significantly higher rate of total complications in the NASCIS-II methylprednisolone group. These findings support guideline recommendations against routine administration of methylprednisolone in acute TSCI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2015.3963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638202PMC
November 2015

Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations.

Anesthesiology 2015 May;122(5):974-84

From the Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.P.R., N.S.R.); Northwestern University Feinberg School of Medicine, Chicago, Illinois (H.T.B.); EvergreenHealth, Kirkland, Washington (P.D., R.B.); Vanderbilt University School of Medicine, Nashville, Tennessee (M.H.); University of California San Diego, San Diego, California (M.W.); Washington University School of Medicine, St. Louis, Missouri (K.D.R.); Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio (R.W.R.); Interventional Spine Specialists, Kenner, Louisiana (C.A.); Rush Medical College, Chicago, Illinois (A.B.); Ahwatukee Sports and Spine, Phoenix, Arizona (D.S.K.); University of Newcastle, Newcastle, Australia (N.B.); University of Saskatchewan, Saskatoon, Saskatchewan, Canada (D.R.F.); Southside Pain Solutions, Danville, Virginia (E.F.); APM Spine and Sports Physicians, Virginia Beach, Virginia (S.H.); Mayo Clinic Florida, Jacksonville, Florida (J. Stone); Virginia Mason Medical Center, Seattle, Washington (K.V.); Neuroimaging and Interventional Spine Services, LLC, Ridgefield, Connecticut (G.L.); NewSouth NeuroSpine, Flowood, Mississippi (J. Summers); Danbury Hospital, Danbury, Connecticut (D.K.); University of North Carolina School of Medicine, Winston Salem, North Carolina (D.O.); and Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin (S.T.).

Background: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections.

Methods: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process.

Results: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration.

Conclusion: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ALN.0000000000000614DOI Listing
May 2015

The influence of time from injury to surgery on motor recovery and length of hospital stay in acute traumatic spinal cord injury: an observational Canadian cohort study.

J Neurotrauma 2015 May 19;32(9):645-54. Epub 2014 Nov 19.

1 Division of Spine, Department of Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada .

To determine the influence of time from injury to surgery on neurological recovery and length of stay (LOS) in an observational cohort of individuals with traumatic spinal cord injury (tSCI), we analyzed the baseline and follow-up motor scores of participants in the Rick Hansen Spinal Cord Injury Registry to specifically assess the effect of an early (less than 24 h from injury) surgical procedure on motor recovery and on LOS. One thousand four hundred and ten patients who sustained acute tSCIs with baseline American Spinal Injury Association Impairment Scale (AIS) grades A, B, C, or D and were treated surgically were analyzed to determine the effect of the timing of surgery (24, 48, or 72 h from injury) on motor recovery and LOS. Depending on the distribution of data, we used different types of generalized linear models, including multiple linear regression, gamma regression, and negative binomial regression. Persons with incomplete AIS B, C, and D injuries from C2 to L2 demonstrated motor recovery improvement of an additional 6.3 motor points (SE=2.8 p<0.03) when they underwent surgical treatment within 24 h from the time of injury, compared with those who had surgery later than 24 h post-injury. This beneficial effect of early surgery on motor recovery was not seen in the patients with AIS A complete SCI. AIS A and B patients who received early surgery experienced shorter hospital LOS. While the issues of when to perform surgery and what specific operation to perform remain controversial, this work provides evidence that for an incomplete acute tSCI in the cervical, thoracic, or thoracolumbar spine, surgery performed within 24 h from injury improves motor neurological recovery. Early surgery also reduces LOS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2014.3632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410758PMC
May 2015

Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes.

Spine (Phila Pa 1976) 2014 Oct;39(22 Suppl 1):S129-35

From the Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada.

Study Design: Retrospective medical record review.

Objective: To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment.

Summary Of Background Data: The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process.

Methods: We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons.

Results: We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment.

Conclusion: A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000000574DOI Listing
October 2014

Lumbosacral discitis-osteomyelitis after mesh abdominosacrocolpopexy.

Spine J 2015 Jan 10;15(1):194-5. Epub 2014 Aug 10.

Division of Neurosurgery, Department of Surgery, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7H 0N3, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2014.08.004DOI Listing
January 2015

Incorporating the Spine Instability Neoplastic Score into a Treatment Strategy for Spinal Metastasis: LMNOP.

Global Spine J 2014 Jun 28;4(2):129-36. Epub 2014 Apr 28.

Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Study Design Review. Objective To describe a decision framework that incorporates key factors to be considered for optimal treatment of spinal metastasis and highlight how this system incorporates the Spinal Instability Neoplastic Score (SINS). Methods We describe how treatment options for spinal metastasis have broadened in recent years with advancements in stereotactic radiosurgery, vertebral augmentation, and other minimally invasive techniques. We discuss classification-based approaches to the treatment of spinal metastasis versus principles-based approaches and argue that the latter may be more appropriate for optimal patient informed consent. Case examples are provided. Results Scoring systems at best produce an estimate of life expectancy but fall short in incorporating all of the relevant factors that determine which treatment(s) may be indicated. We advocate a principle-based decision framework called LMNOP that considers: (L) location of disease with respect to the anterior and/or posterior columns of the spine and number of spinal levels involved (contiguous or non-contiguous); (M) mechanical instability as graded by SINS; (N) neurology (symptomatic epidural spinal cord compression); (O) oncology (histopathologic diagnosis), particularly with respect to radiosensitivity; and (P) patient fitness, patient wishes, prognosis (which is mostly dependent on tumor type), and response to prior therapy. Conclusions LMNOP is the first systematic approach to spinal metastasis that incorporates SINS. It is easy to remember, it addresses clinical factors not directly addressed by other systems, and it is adaptable to changes in technology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0034-1375560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078113PMC
June 2014

Hospitalized head and spine injuries on Saskatchewan farms.

Can J Neurol Sci 2014 Jul;41(4):436-41

Introduction: With over 44,000 individual farms, farm dwellers account for 11% of the population of Saskatchewan. There is limited data on brain and spine injuries acquired on farms. The objective of this study was to evaluate the epidemiology of head and spine injuries on Saskatchewan farms to assist the development of injury prevention initiatives.

Methods: Using the Canadian Centre for Agricultural Health and Safety's Saskatchewan Farm Injury Surveillance Database, farm-related head and spine injuries hospitalized > 24 hours were examined (1990-2007). We collected information regarding the type and mechanism of injury as well as the geographic location of both the injury and treatment.

Results: The database captured 390 brain injuries and 228 spine injuries, including 16 spinal cord injuries. The majority of patients were male (73.3% of head injuries and 84.2% of spine injuries). The highest risk age groups were 50-59 years, with 24.1% of the spine injuries, and 40-49 years, with 19.2% of the head injuries. The most common causes of injury were falls and/or machinery-related. The average annual incidence of farm-related spine and head injury were 10.8 and 17.6 per 100,000 farm population, respectively. All patients included in this study were hospitalized for over 24 hours, with 44.7% of spine injuries spending over one week in hospital, and 20% of head injuries spending over three days in hospital.

Conclusions: Injury prevention initiatives should be targeted towards males aged 40-59 years residing in the southern areas of the province, with increased awareness towards the dangers of falls and operating tractors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/s031716710001845xDOI Listing
July 2014
-->