Publications by authors named "Nicolas Dea"

67 Publications

Characterization of Hyperacute Neuropathic Pain after Spinal Cord Injury: A Prospective Study.

J Pain 2021 Jul 21. Epub 2021 Jul 21.

International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada; Hugill Centre for Anesthesia, Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address:

There is currently a lack of information regarding neuropathic pain in the very early stages of spinal cord injury (SCI). In the present study, neuropathic pain was assessed using the Douleur Neuropathique 4 Questions (DN4) for the patient's worst pain within the first 5 days of injury (i.e., hyperacute) and on follow-up at 3, 6, and 12 months. Within the hyperacute time-frame (i.e., 5 days), at- and below level neuropathic pain were reported as the worst pain in 23% (n=18) and 5% (n=4) of individuals with SCI, respectively. Compared to the neuropathic pain observed in this hyperacute setting, late presenting neuropathic pain was characterized by more intense painful electrical and cold sensations, but less itching sensations. Phenotypic differences between acute and late neuropathic pain support the incorporation of timing into a mechanism-based classification of neuropathic pain after SCI. The diagnosis of acute neuropathic pain after SCI is challenged by the presence of nociceptive and neuropathic pains, with the former potentially masking the latter. This may lead to an underestimation of the incidence of neuropathic pain during the very early, hyperacute time points post-injury. Trial registration: ClinicalTrials.gov (Identifier: NCT01279811) Perspective: This article presents distinct pain phenotypes of hyperacute and late presenting neuropathic pain after spinal cord injury and highlights the challenges of pain assessments in the acute phase after injury. This information may be relevant to clinical trial design and broaden our understanding of neuropathic pain mechanisms after spinal cord injury.
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http://dx.doi.org/10.1016/j.jpain.2021.06.013DOI Listing
July 2021

Accuracy of hospital-based surveillance systems for surgical site infection after adult spine surgery: A Bayesian latent class analysis.

J Hosp Infect 2021 Jul 14. Epub 2021 Jul 14.

Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada.

Background: Surgical site infections (SSIs) of the spine are morbid and costly complications. An accurate surveillance system is required to properly describe the disease burden and the impact of interventions that mitigate SSI risk. Unfortunately, uniform approaches to conducting SSI surveillance are lacking because of varying SSI case definitions, the lack of a perfect reference case definition and heterogeneous data sources.

Aim: We assessed the accuracy of 4 independent data sources that capture SSIs after spine surgery, with estimation of a measurement error-adjusted SSI incidence.

Methods: A Bayesian latent class model assessed the sensitivity/specificity of each data source to identify SSI and to estimate a measurement-error adjusted incidence. The four data sources used were: the discharge abstract database (DAD), the National Surgical Quality Improvement Program (NSQIP) database, the Infection Prevention and Control Canada (IPAC) database, and the Spine Adverse Events Severity database.

Findings: A total of 904 patients underwent spine surgery in 2017. The most sensitive data source was DAD (0.799, 95% CrI 0.597, 0.943), while the least sensitive was NSQIP (0.497, 95% CrI 0.308, 0.694). The most specific data source was IPAC (0.997, 95% CrI 0.993, 1.000) and the least specific was DAD (0.969, 95% CrI 0.956, 0.981). The measurement error-adjusted SSI incidence was 0.030 (95% CrI 0.019, 0.045). The crude incidence using the DAD over-estimated the incidence, and the 3 other data sources under-estimated it.

Conclusion: SSI surveillance in the spine surgery population is feasible using several data sources, provided that measurement error is considered.
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http://dx.doi.org/10.1016/j.jhin.2021.07.005DOI Listing
July 2021

Evidence-based Recommendations for Spine Surgery.

Spine (Phila Pa 1976) 2021 Jul;46(14):975-982

Department of Orthopaedic Surgery, Bone and Joint Institute at Hartford Hospital, and Orthopaedic Associates of Hartford, Hartford, CT.

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http://dx.doi.org/10.1097/BRS.0000000000004091DOI Listing
July 2021

Proteomic Portraits Reveal Evolutionarily Conserved and Divergent Responses to Spinal Cord Injury.

Mol Cell Proteomics 2021 Jun 12;20:100096. Epub 2021 Jun 12.

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

Despite the emergence of promising therapeutic approaches in preclinical studies, the failure of large-scale clinical trials leaves clinicians without effective treatments for acute spinal cord injury (SCI). These trials are hindered by their reliance on detailed neurological examinations to establish outcomes, which inflate the time and resources required for completion. Moreover, therapeutic development takes place in animal models whose relevance to human injury remains unclear. Here, we address these challenges through targeted proteomic analyses of cerebrospinal fluid and serum samples from 111 patients with acute SCI and, in parallel, a large animal (porcine) model of SCI. We develop protein biomarkers of injury severity and recovery, including a prognostic model of neurological improvement at 6 months with an area under the receiver operating characteristic curve of 0.91, and validate these in an independent cohort. Through cross-species proteomic analyses, we dissect evolutionarily conserved and divergent aspects of the SCI response and establish the cerebrospinal fluid abundance of glial fibrillary acidic protein as a biochemical outcome measure in both humans and pigs. Our work opens up new avenues to catalyze translation by facilitating the evaluation of novel SCI therapies, while also providing a resource from which to direct future preclinical efforts.
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http://dx.doi.org/10.1016/j.mcpro.2021.100096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8260874PMC
June 2021

Patient perspective: diagnosis and prognosis of acute spinal cord injuries.

Spinal Cord 2021 Jun 3. Epub 2021 Jun 3.

Combined Neurosurgical and Orthopaedic Spine Program, Blusson Spinal Cord Centre, Vancouver General Hospital, Vancouver, British Columbia, Canada.

Study Design: Qualitative study.

Objectives: The purpose of this study is to understand the patient perspective after diagnosis of an acute traumatic spinal cord injury (tSCI). Discussing the diagnosis and prognosis of a tSCI with a patient can be a challenging experience for both the patient and the physician. As such, this paper attempts to better understand the patient experience to improve communication when discussing this life-altering injury.

Setting: Vancouver General Hospital, Vancouver, British Columbia, Canada.

Methods: This study is a qualitative study utilizing grounded theory and semi-structured interviews. The interview transcripts were manually coded using manifest and latent content analysis. Major and minor codes were identified and discussed.

Results: In total, 17 interviews were conducted, fifteen individuals with tSCI who received acute care at Vancouver General Hospital (VGH) and eleven family members were interviewed. Patient participants were interviewed individually or in a paired interview with a participating family member. Patient participants had varying spinal cord injuries from AIS A-D. Two major themes were identified from the interviews. The first major theme was physician demeanor (general approach and attitude towards patients) and the second major theme was delivery of information (content, timing, and source).

Conclusions: This study summarizes the preferences of patients who sustained a tSCI discussions regarding their diagnosis and prognosis in the acute care setting. The goal of this study is to help guide physician interactions at this difficult and vulnerable time for patients with hopes to improve patient care through effective communication.
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http://dx.doi.org/10.1038/s41393-021-00641-5DOI Listing
June 2021

Introduction. Treatment of spinal cord and spinal axial tumors.

Neurosurg Focus 2021 05;50(5):E1

5Department of Oncology, Queen's University, Kingston, Ontario, Canada.

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http://dx.doi.org/10.3171/2021.2.FOCUS21113DOI Listing
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

Characterization of Cerebrospinal Fluid Ubiquitin C-Terminal Hydrolase L1 (UCH-L1) as a Biomarker of Human Acute Traumatic Spinal Cord Injury.

J Neurotrauma 2021 May 3. Epub 2021 May 3.

International Collaboration on Repair Discoveries (ICORD), Blusson Spinal Cord Center, University of British Columbia, Vancouver, British Columbia, Canada.

A major obstacle for translational research in acute spinal cord injury (SCI) is the lack of biomarkers that can objectively stratify injury severity and predict outcome. Ubiquitin C-terminal hydrolase L1 (UCH-L1) is a neuron-specific enzyme that shows promise as a diagnostic biomarker in traumatic brain injury (TBI), but has not been studied in SCI. In this study, cerebrospinal fluid (CSF) and serum samples were collected over the first 72-96 h post-injury from 32 acute SCI patients who were followed prospectively to determine neurological outcomes at 6 months post-injury. UCH-L1 concentration was measured using the Quanterix Simoa platform (Quanterix, Billerica, MA) and correlated to injury severity, time, and neurological recovery. We found that CSF UCH-L1 was significantly elevated by 10- to 100-fold over laminectomy controls in an injury severity- and time-dependent manner. Twenty-four-hour post-injury CSF UCH-L1 concentrations distinguished between American Spinal Injury Association Impairment Scale (AIS) A and AIS B, and AIS A and AIS C patients in the acute setting, and predicted who would remain "motor complete" (AIS A/B) at 6 months with a sensitivity of 100% and a specificity of 86%. AIS A patients who did not improve their AIS grade at 6 months post-injury were characterized by sustained elevations in CSF UCH-L1 up to 96 h. Similarly, the failure to gain >8 points on the total motor score at 6 months post-injury was associated with higher 24-h CSF UCH-L1. Unfortunately, serum UCH-L1 levels were not informative about injury severity or outcome. In conclusion, CSF UCH-L1 in acute SCI shows promise as a biomarker to reflect injury severity and predict outcome.
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http://dx.doi.org/10.1089/neu.2020.7352DOI Listing
May 2021

Management of recurrent or progressive spinal metastases: reirradiation techniques and surgical principles.

Neurooncol Pract 2020 Nov 18;7(Suppl 1):i45-i53. Epub 2020 Nov 18.

Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.

With the growing incidence of new cases and the increasing prevalence of patients living longer with spine metastasis, a methodological approach to the management of patients with recurrent or progressive disease is increasing in relevance and importance in clinical practice. As a result, disease management has evolved in these patients using advanced surgical and radiotherapy technologies. Five key goals in the management of patients with spine metastases include providing pain relief, controlling metastatic disease at the treated site, improving neurologic deficits, maintaining or improving functional status, and minimizing further mechanical instability. The focus of this review is on advanced reirradiation techniques, given that the majority of patients will be treated with upfront conventional radiotherapy and further treatment on progression is often limited by the cumulative tolerance of nearby organs at risk. This review will also discuss novel surgical approaches such as separation surgery, minimally invasive percutaneous instrumentation, and laser interstitial thermal therapy, which is increasingly being coupled with spine reirradiation to maximize outcomes in this patient population. Lastly, given the complexities of managing recurrent spinal disease, this review emphasizes the importance of multidisciplinary care from neurosurgery, radiation oncology, medical oncology, neuro-oncology, rehabilitation medicine, and palliative care.
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http://dx.doi.org/10.1093/nop/npaa045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705530PMC
November 2020

Evidence-based Recommendations for Spine Surgery.

Spine (Phila Pa 1976) 2021 Feb;46(4):E277-E285

Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT.

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http://dx.doi.org/10.1097/BRS.0000000000003838DOI Listing
February 2021

Factors Associated With Return to Work After Surgery for Degenerative Cervical Spondylotic Myelopathy: Cohort Analysis From the Canadian Spine Outcomes and Research Network.

Global Spine J 2020 Oct 16:2192568220958669. Epub 2020 Oct 16.

Vancouver General Hospital, Vancouver, British Columbia, Canada.

Study Design: Retrosepctive analysis of prospectively collected data from the multicentre Canadian Surgical Spine Registry (CSORN).

Objective: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in North America. Few studies have evaluated return to work (RTW) rates after DCM surgery. Our goals were to determine rates and factors associated with postoperative RTW in surgically managed patients with DCM.

Methods: Data was derived from the prospective, multicenter Canadian Spine Outcomes and Research Network (CSORN). From this cohort, we included all nonretired patients with at least 1-year follow-up. The RTW rate was defined as the proportion of patients with active employment at 1 year from the time of surgery. Unadjusted and adjusted analyses were used to identify patient characteristics, disease, and treatment variables associated with RTW.

Results: Of 213 surgically treated DCM patients, 126 met eligibility, with 49% working and 51% not working in the immediate period before surgery; 102 had 12-month follow-up data. In both the unadjusted and the adjusted analyses working preoperatively and an anterior approach were associated with a higher postoperative RTW ( < .05), there were no significant differences between the postoperative employment groups with respect to age, gender, preoperative mJOA (modified Japanese Orthopaedic Association) score, and duration of symptoms ( > .05). Active preoperative employment (odds ratio = 15.4, 95% confidence interval = 4.5, 52.4) and anterior surgical procedures (odds ratio = 4.7, 95% confidence interval = 1.2, 19.6) were associated with greater odds of RTW at 1 year.

Conclusions: The majority of nonretired patients undergoing surgery for DCM had returned to work 12 months after surgery; active preoperative employment and anterior surgical approach were associated with RTW in this analysis.
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http://dx.doi.org/10.1177/2192568220958669DOI Listing
October 2020

The Effect of Perioperative Adverse Events on Long-Term Patient-Reported Outcomes After Lumbar Spine Surgery.

Neurosurgery 2021 01;88(2):420-427

Department of Surgery, Vancouver General Hospital/University of British Columbia, Vancouver, Canada.

Background: Perioperative adverse events (AEs) lead to patient disappointment and greater costs. There is a paucity of data on how AEs affect long-term outcomes.

Objective: To examine perioperative AEs and their impact on outcome after lumbar spine surgery.

Methods: A total of 3556 consecutive patients undergoing surgery for lumbar degenerative disorders enrolled in the Canadian Spine Outcomes and Research Network were analyzed. AEs were defined using the validated Spine AdVerse Events Severity system. Outcomes at 3, 12, and 24 mo postoperatively included the Owestry Disability Index (ODI), 12-Item Short-Form Health Survey (SF-12) Physical (PCS) and Mental (MCS) Component Summary scales, visual analog scale (VAS) leg and back, EuroQol-5D (EQ5D), and satisfaction.

Results: AEs occurred in 767 (21.6%) patients, and 85 (2.4%) patients suffered major AEs. Patients with major AEs had worse ODI scores and did not reach minimum clinically important differences at 2 yr (no AE: 25.7 ± 19.2, major: 36.4 ± 19.1, P < .001). Major AEs were associated with worse ODI scores on multivariable linear regression (P = .011). PCS scores were lower after major AEs (43.8 ± 9.5, vs 37.7 ± 20.3, P = .002). On VAS leg and back and EQ5D, the 2-yr outcomes were significantly different between the major and no AE groups (<0.01), but these differences were small (VAS leg: 3.4 ± 3.0 vs 4.0 ± 3.3; VAS back: 3.5 ± 2.7 vs 4.5 ± 2.6; EQ5D: 0.75 ± 0.2 vs 0.64 ± 0.2). SF12 MCS scores were not different. Rates of satisfaction were lower after major AEs (no AE: 84.6%, major: 72.3%, P < .05).

Conclusion: Major AEs after lumbar spine surgery lead to worse functional outcomes and lower satisfaction. This highlights the need to implement strategies aimed at reducing AEs.
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http://dx.doi.org/10.1093/neuros/nyaa427DOI Listing
January 2021

Back pain in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

Spine J 2020 12 19;20(12):1940-1947. Epub 2020 Aug 19.

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

Of Background Data: Surgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication. Surgery improves patients' disability and lower extremity symptoms, but less is known about the impact on back pain.

Objective: To evaluate changes in back pain after surgery and identify factors associated with these changes in surgically-treated DLS.

Study Design: Retrospective review of prospectively collected data.

Methods: There were 486 consecutive patients with surgically-treated DLS who were enrolled in the Canadian Spine Outcomes Research Network prospective registry and identified for this study. Patients had demographic data, clinical information, disability (Oswestry Disability Index), and back pain rating scores collected prospectively at baseline, and 12 months follow-up RESULTS: Of the 486 DLS patients, 376 (77.3%) were successfully followed at 12 months. Mean age at baseline was 66.7 (standard deviation [SD] 9.2) years old, and 63% were female. Back pain improved significantly at 12 months, compared with baseline (p<.001). Improvement in Numeric Rating Scale (NRS)-back pain ratings was on average 2.97 (SD 2.5) points at one year and clinically significant improvement in back pain was observed in 75% of patients (minimal clinically important difference (MCID) NRS-Pain 1.2 points). Multivariable logistic regression revealed five factors associated with meeting MCID NRS-back pain at 12 month follow up: higher baseline back pain, better baseline physical function (higher SF-12 Physical Component Score), symptoms duration less than 1 to 2 years, and having no intraoperative adverse events.

Conclusions: Back pain improved significantly for patients treated surgically for DLS at 1-year follow-up.
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http://dx.doi.org/10.1016/j.spinee.2020.08.009DOI Listing
December 2020

Effectiveness of silver alloy-coated silicone urinary catheters in patients with acute traumatic cervical spinal cord injury: Results of a quality improvement initiative.

J Clin Neurosci 2020 Aug 11;78:135-138. Epub 2020 Jun 11.

Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedic Surgery, University of British Columbia, Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, 818 West 10th Avenue, Vancouver, BC V5Z 1M9, Canada. Electronic address:

Patients with acute traumatic cervical spinal cord injury (ATCSCI) have an increased risk of catheter-associated urinary tract infection (CAUTI). The effectiveness of silver alloy-coated silicone urinary catheters (SACC) in preventing CAUTI in ATCSCI is unknown and was the objective of this study. We performed a quality improvement initiative in an attempt to reduce CAUTI in patients undergoing spine surgery at a single quaternary center. Prior to July 2015, all patients received a latex indwelling catheter (LIC). All patients with ATCSCI with limited hand function (AIS A,B, or C) received a SACC. Incidence of CAUTI, microbiology, duration of infection, antibiotic susceptibility, and catheter-associated adverse events were recorded prospectively. We studied 3081 consecutive patients over the three years, of whom 302 (9.8%) had ATCSCI; 63% of ATCSCI patients were ASIA Impairment Scale (AIS) A or B. The overall rate of CAUTI was 19% (585/3081), and was 38% (116/302) in patients with ATCSCI. Of 178 ATCSCI patients with LIC, 100 (56%) developed a CAUTI compared with 28 of 124 (23%) patients with SACC (p < 0.05). Poly-microbial and gram-positive infection was more common in LIC than in SACC (p < 0.05). Median duration of infection was 9 days in SACC group and 12 days in LIC group (p = 0.08). Resistance to trimethoprim (p < 0.001) and ciprofloxacin (p < 0.05) were more common in LIC group. There was no difference in catheter-associated adverse events or length of stay between the groups. This quality improvement initiative illustrates the effectiveness of antiseptic silver alloy-coated silicone urinary catheters in patients with ATCSCI. In our population, the use of SACC reduces the incidence and the complexity of CAUTI.
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http://dx.doi.org/10.1016/j.jocn.2020.05.036DOI Listing
August 2020

Clinical predictors of achieving the minimal clinically important difference after surgery for cervical spondylotic myelopathy: an external validation study from the Canadian Spine Outcomes and Research Network.

J Neurosurg Spine 2020 Apr 10:1-9. Epub 2020 Apr 10.

1University of Calgary Spine Program, University of Calgary, Alberta.

Objective: Recently identified prognostic variables among patients undergoing surgery for cervical spondylotic myelopathy (CSM) are limited to two large international data sets. To optimally inform shared clinical decision-making, the authors evaluated which preoperative clinical factors are significantly associated with improvement on the modified Japanese Orthopaedic Association (mJOA) scale by at least the minimum clinically important difference (MCID) 12 months after surgery, among patients from the Canadian Spine Outcomes and Research Network (CSORN).

Methods: The authors performed an observational cohort study with data that were prospectively collected from CSM patients at 7 centers between 2015 and 2017. Candidate variables were tested using univariable and multiple binomial logistic regression, and multiple sensitivity analyses were performed to test assumptions about the nature of the statistical models. Validated mJOA MCIDs were implemented that varied according to baseline CSM severity.

Results: Among 205 patients with CSM, there were 64 (31%) classified as mild, 86 (42%) as moderate, and 55 (27%) as severe. Overall, 52% of patients achieved MCID and the mean change in mJOA score at 12 months after surgery was 1.7 ± 2.6 points (p < 0.01), but the subgroup of patients with mild CSM did not significantly improve (mean change 0.1 ± 1.9 points, p = 0.8). Univariate analyses failed to identify significant associations between achieving MCID and sex, BMI, living status, education, smoking, disability claims, or number of comorbidities. After adjustment for potential confounders, the odds of achieving MCID were significantly reduced with older age (OR 0.7 per decade, 95% CI 0.5-0.9, p < 0.01) and higher baseline mJOA score (OR 0.8 per point, 95% CI 0.7-0.9, p < 0.01). The effects of symptom duration (OR 1.0 per additional month, 95% CI 0.9-1.0, p = 0.2) and smoking (OR 0.4, 95% CI 0.2-1.0, p = 0.06) were not statistically significant.

Conclusions: Surgery is effective at halting the progression of functional decline with CSM, and approximately half of all patients achieve the MCID. Data from the CSORN confirmed that older age is independently associated with poorer outcomes, but novel findings include that patients with milder CSM did not experience meaningful improvement, and that symptom duration and smoking were not important. These findings support a nuanced approach to shared decision-making that acknowledges some prognostic uncertainty when weighing the various risks, benefits, and alternatives to surgical treatment.
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http://dx.doi.org/10.3171/2020.2.SPINE191495DOI Listing
April 2020

Surgical Strategies for Chordoma.

Neurosurg Clin N Am 2020 Apr 16;31(2):251-261. Epub 2020 Jan 16.

Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, Yawkey Building, Room 3.922, 55 Fruit Street, Boston, MA 02114, USA.

Chordomas are rare tumors of the axial skeleton whose slow growth belies a relentless tumor with a propensity for recurrence and late metastasis. Local control remains an issue with chordoma in spite of aggressive operative management. High local failure rates have led to the exploration of alternative methods of treatment. Radiation continues to gain acceptance as an adjuvant to surgery and, in some cases, as a standalone treatment. However, the use of radiation remains controversial, and operative management remains the standard of care in spite of relatively high morbidity.
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http://dx.doi.org/10.1016/j.nec.2019.11.007DOI Listing
April 2020

Correction: The influence of neurological examination timing within hours after acute traumatic spinal cord injuries: an observational study.

Spinal Cord 2020 Feb;58(2):255

Division of Spine, University of British Columbia, 6400-818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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http://dx.doi.org/10.1038/s41393-020-0413-yDOI Listing
February 2020

International consensus recommendations for target volume delineation specific to sacral metastases and spinal stereotactic body radiation therapy (SBRT).

Radiother Oncol 2020 04 23;145:21-29. Epub 2019 Dec 23.

Department of Radiation Oncology, BC Cancer - Vancouver Centre, Canada.

Background And Purpose: To interrogate inter-observer variability in gross tumour volume (GTV) and clinical target volume (CTV) delineation specific to the treatment of sacral metastases with spinal stereotactic body radiation therapy (SBRT) and develop CTV consensus contouring recommendations.

Materials And Methods: Nine specialists with spinal SBRT expertise representing 9 international centres independently contoured the GTV and CTV for 10 clinical cases of metastatic disease within the sacrum. Agreement between physicians was calculated with an expectation minimisation algorithm using simultaneous truth and performance level estimation (STAPLE) and with kappa statistics. Optimised confidence level consensus contours were obtained using a voxel-wise maximum likelihood approach and the STAPLE contours for GTV and CTV were based on an 80% confidence level.

Results: Mean GTV STAPLE agreement sensitivity and specificity was 0.70 (range, 0.54-0.87) and 1.00, respectively, and 0.55 (range, 0.44-0.64) and 1.00 for the CTV, respectively. Mean GTV and CTV kappa agreement was 0.73 (range, 0.59-0.83) and 0.59 (range, 0.41-0.70), respectively. Optimised confidence level consensus contours were identified by STAPLE analysis. Consensus recommendations for the CTV include treating the entire segment containing the disease in addition to the immediate adjacent bony anatomic segment at risk of microscopic extension.

Conclusion: Consensus recommendations for CTV target delineation specific to sacral metastases treated with SBRT were established using expert contours. This is a critical first step to achieving standardisation of target delineation practice in the sacrum and will serve as a baseline for meaningful pattern of failure analyses going forward.
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http://dx.doi.org/10.1016/j.radonc.2019.11.026DOI Listing
April 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

The influence of neurological examination timing within hours after acute traumatic spinal cord injuries: an observational study.

Spinal Cord 2020 Feb 8;58(2):247-254. Epub 2019 Oct 8.

Division of Spine, University of British Columbia, 6400-818 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.

Study Design: Cohort study.

Objectives: It is widely accepted that the prediction of long-term neurologic outcome after traumatic spinal cord injury (SCI) can be done more accurately with neurological examinations conducted days to weeks post injury. However, modern clinical trials of neuroprotective interventions often require patients be examined and enrolled within hours. Our objective was to determine whether variability in timing of neurological examinations within 48 h after SCI is associated with differences in observations of follow-up neurologic recovery.

Setting: Level I trauma hospital.

Methods: An observational analysis testing for differences in AIS conversion rates and changes in total motor scores by neurological examination timing, controlling for potential confounders with multivariate stepwise regression.

Results: We included 85 patients, whose mean times from injury to baseline and follow-up examinations were 11.8 h (SD 9.8) and 208.2 days (SD 75.2), respectively. AIS conversion by 1+ grade was significantly more likely in patients examined at ≤4 h in comparison with later examination (78% versus 47%, RR = 1.66, p = 0.04), even after controlling for timing of surgery, age, and sex (OR 5.0, 95% CI 1.1-10, p = 0.04). We failed to identify any statistically significant associations for total motor score recovery in unadjusted or adjusted analyses.

Conclusions: AIS grade conversion was significantly more likely in those examined ≤4 h of injury; the effect of timing on motor scores remains uncertain. Variability in neurological examination timing within hours after acute traumatic SCI may influence observations of long-term neurological recovery, which could introduce bias or lead to errors in interpretation of studies of therapeutic interventions.
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http://dx.doi.org/10.1038/s41393-019-0359-0DOI Listing
February 2020

Perioperative adverse events following surgery for primary bone tumors of the spine and en bloc resection for metastases.

J Neurosurg Spine 2019 Sep 27:1-8. Epub 2019 Sep 27.

1Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedic Surgery, and.

Objective: Surgical treatment of primary bone tumors of the spine and en bloc resection for isolated metastases are complex and challenging. Operative care is fraught with complications, though the true incidence and predictors of adverse events (AEs), length of stay (LOS), and mortality in this population remain poorly understood. The primary objective of this study was to describe the incidence and predictors of perioperative AEs in these patients. Secondary objectives included the determination of the incidence and predictors of admission to the intensive care unit (ICU), unanticipated reoperation during the same admission, hospital LOS, and mortality.

Methods: In this retrospective analysis of prospectively collected data, the authors included consecutive patients at a single quaternary care referral center (January 1, 2009, to September 30, 2018) who underwent either surgery for a primary bone tumor of the spine or an en bloc resection for an isolated spinal metastasis. Information on perioperative AEs, demographic data, primary tumor histology, neurological status, surgical variables, pathological margins, Enneking appropriateness, LOS, ICU stay, reoperation during the same admission period, and in-hospital mortality was collected prospectively in the institutional database. The modified frailty score was extracted retrospectively.

Results: One hundred thirteen patients met the inclusion criteria: 98 with primary bone tumors and 15 with isolated metastases. The cohort was 59% male, and the mean age was 49 years (SD 19 years). Overall, 79% of the patients experienced at least 1 AE. The median number of AEs per patient was 2 (IQR 0-4 AEs), and the median LOS was 16 days (IQR 9-32 days). No in-hospital deaths occurred in the cohort. Thirty-two patients (28%) required an ICU stay and 19% underwent an unanticipated second surgery during their admission. A longer surgical duration was associated with a higher likelihood of AEs (OR 1.21/hour, 95% CI 1.06-1.37, p = 0.005), longer ICU stay (OR 1.35/hour, 95% CI 1 1.20-1.52, p < 0.001), and reoperation (OR 1.001/hour, 95% CI 1.0003-1.003, p = 0.012). Longer hospital LOS was independently predicted by older age, female sex, upper cervical and sacral location of the tumor, surgical duration, preoperative neurological deficit, presence of AEs, and higher modified frailty index score.

Conclusions: Surgeries for primary bone tumors and en bloc resection for metastatic tumors are associated with a high incidence of perioperative AEs. Surgical duration predicts complications, reoperation, LOS, and ICU stay.
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http://dx.doi.org/10.3171/2019.6.SPINE19587DOI Listing
September 2019

Bilateral cervical facet dislocations at two adjacent levels: A case report.

Surg Neurol Int 2019 26;10:48. Epub 2019 Mar 26.

Vancouver Spinal Surgery Institute and Department of Surgery, Division of Neurosurgery, Vancouver, British Columbia, Canada.

Background: Cervical facet dislocations are rare in patients sustaining traumatic subaxial injuries. They occur due to hyperflexion-distraction and can occur unilaterally or bilaterally resulting in significant spinal instability. Bilateral facet dislocations at one level are less common than unilateral dislocations, while bilateral facet dislocations at adjacent spinal levels have only been reported twice in literature.

Case Description: A 31-year-old male presented with bilateral facet dislocations at two adjacent cervical levels (C6/C7 and C7/T1) following a fall from 40 to 50 feet. The patient had undergone a C6/C7 disk arthroplasty a few weeks before the traumatic event.

Conclusion: Here, we present the unique case of cervical bilateral jumped facets occurring at two adjacent levels (i.e., C6-C7 and C7-T1). Notably, the antecedent cervical C6-C7 arthroplasty likely contributed to the altered load distribution, leading to this unusual instance of bilateral adjacent level facet dislocations. In such cases, surgical reduction and fixation may prove technically challenging warranting, therefore, careful preoperative planning.
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http://dx.doi.org/10.25259/SNI-95-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743703PMC
March 2019

Sarcopenia, but not frailty, predicts early mortality and adverse events after emergent surgery for metastatic disease of the spine.

Spine J 2020 01 1;20(1):22-31. Epub 2019 Sep 1.

Vancouver General Hospital, Vancouver Spine Surgery Institute, 818 west 10th Avenue, Vancouver, British Columbia, V5Z 1M9 Canada.

Background Context: Frailty and sarcopenia variably predict adverse events (AEs) in a number of surgical populations.

Purpose: The aim of this study was to investigate the ability of frailty and sarcopenia to independently predict early mortality and AEs following urgent surgery for metastatic disease of the spine.

Study Design: A single institution, retrospective cohort study.

Patient Sample: One hundred eight patients undergoing urgent surgery for spinal metastases from 2009 to 2015.

Outcome Measures: The incidence of AEs including 1- and 3-month mortality.

Methods: Sarcopenia was defined using the L3 Total Psoas Area/Vertebral body Area (L3-TPA/VB) technique on CT. The modified Frailty Index (mFI), Metastatic Frailty Index (MSTFI) and the Bollen prognostic scales were calculated for each patient. Additional data included demographics, tumor type and burden, neurological status, the extent of surgical treatment and the use of radiation-therapy. Spearman correlation test, logistic regression and Kaplan-Meier were used to study the relation between the outcomes measures and potential predictors (L3-TPA/VB, MSTFI, mFI, and the Bollen prognostic scales).

Results: Eighty-five percent of patients had at least one acute AE. Sarcopenia predicted the occurrence of at least one postop AE (L3-TPA/VB, 1.07±0.40 vs. 1.25±0.52; p=.031). Sarcopenia (L3-TPA/VB) and the degree of neurological impairment were predictive of postoperative AE but MFI or MSTFI were not. Sarcopenia predicted 3-month mortality, independent of primary tumor type (L3-TPA/VB: 0.86±0.27 vs. 1.12±0.41; p<.001). Kaplan-Meyer analysis showed L3-TPA/VB and the Bollen Scale to significantly discriminate patient survival.

Conclusions: Sarcopenia, easily measured by the L3-TPA/VB on conventional CT, predicts both early postoperative mortality and adverse events in patients undergoing urgent surgery for spinal metastasis, thus providing a practical tool for timely therapeutic decision-making in this complex patient population.
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http://dx.doi.org/10.1016/j.spinee.2019.08.012DOI Listing
January 2020

Empirical targets for acute hemodynamic management of individuals with spinal cord injury.

Neurology 2019 09 13;93(12):e1205-e1211. Epub 2019 Aug 13.

From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada.

Objective: To determine the hemodynamic conditions associated with optimal neurologic improvement in individuals with acute traumatic spinal cord injury (SCI) who had lumbar intrathecal catheters placed to measure CSF pressure (CSFP).

Methods: Ninety-two individuals with acute SCI were enrolled in this multicenter prospective observational clinical trial. We monitored mean arterial pressure (MAP) and CSFP during the first week after injury and assessed neurologic function at baseline and 6 months after injury. We used relative risk iterations to determine transition points at which the likelihood of either improving neurologically or remaining unchanged neurologically was equivalent. These transition points guided our analyses in which we examined the linear relationships between time spent within target hemodynamic ranges (i.e., clinical adherence) and neurologic recovery.

Results: Relative risk transition points for CSFP, MAP, and spinal cord perfusion pressure (SCPP) were linearly associated with neurologic improvement and directed the identification of key hemodynamic target ranges. Clinical adherence to the target ranges was positively and linearly related to improved neurologic outcomes. Adherence to SCPP targets, not MAP targets, was the best indicator of improved neurologic recovery, which occurred with SCPP targets of 60 to 65 mm Hg. Failing to maintain the SCPP within the target ranges was an important detrimental factor in neurologic recovery, particularly if the target range is set lower.

Conclusion: We provide an empirical, data-driven approach to aid institutions in setting hemodynamic management targets that accept the real-life challenges of adherence to specific targets. Our results provide a framework to guide the development of widespread institutional management guidelines for acute traumatic SCI.
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http://dx.doi.org/10.1212/WNL.0000000000008125DOI Listing
September 2019

Effect of Frailty on Outcome after Traumatic Spinal Cord Injury.

J Neurotrauma 2020 03 8;37(6):839-845. Epub 2019 Nov 8.

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

Frailty negatively affects outcome in elective spine surgery populations. This study sought to determine the effect of frailty on patient outcome after traumatic spinal cord injury (tSCI). Patients with tSCI were identified from our prospectively collected database from 2004 to 2016. We examined effect of patient age, admission Total Motor Score (TMS), and Modified Frailty Index (mFI) on adverse events (AEs), acute length of stay (LOS), in-hospital mortality, and discharge destination (home vs. other). Subgroup analysis (for three age groups: <60, 61-75, and 76+ years), and multi-variable analysis was performed to investigate the impact of age, TMS, and mFI on outcome. For the 634 patients, the mean age was 50.3 years, 77% were male, and falls were the main cause of injury (46.5%). On bivariate analysis, mFI, age at injury, and TMS were predictors of AEs, acute LOS, and in-hospital mortality. After statistical adjustment, mFI was a predictor of LOS ( = 0.0375), but not of AEs ( = 0.1428) or in-hospital mortality ( = 0.1245). In patients <60 years of age, mFI predicted number of AEs, acute LOS, and in-hospital mortality. In those aged 61-75, TMS predicted AEs, LOS, and mortality. In those 76+ years of age, mFI no longer predicted outcome. Age, mFI, and TMS on admission are important determinants of outcome in patients with tSCI. mFI predicts outcomes in those <75 years of age only. The inter-relationship of advanced age and decreased physiological reserve is complex in acute tSCI, warranting further study. Identifying frailty in younger patients with tSCI may be useful for peri-operative optimization, risk stratification, and patient counseling.
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http://dx.doi.org/10.1089/neu.2019.6581DOI Listing
March 2020

Clinical presentation, management and outcomes of sacral metastases: a multicenter, retrospective cohort study.

Ann Transl Med 2019 May;7(10):214

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

Background: Sacral metastases are rare and literature regarding their management is sparse. This multicenter, prospective, observational study aimed to determine health related-quality of life (HRQOL) and pain in patients treated for sacral metastases with surgery and/or radiation therapy (RT). The secondary objectives were to describe the adverse event (AE) profile and change in neurologic function in this population.

Methods: Twenty-three patients presenting with symptomatic sacral metastases were identified from the Epidemiology, Process and Outcomes of Spine Oncology (EPOSO) dataset, a prospective multicenter study on spinal metastases. Patients requiring surgery and/or RT between August 2013 and February 2017 were prospectively enrolled. HRQOL, assessed by the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQv2.0), the Short Form-36 version 2 (SF-36v2), and the EuroQol-5Dimension (EQ-5D) was documented at baseline, 6 weeks, 3 and 6 months post-treatment. Pain numeric rating scale (NRS), AEs, lower extremities motor score (ASIA), and bowel and bladder function were also recorded.

Results: Eight patients underwent surgery ± RT and 15 patients underwent RT alone. Mean age was 59.3 (SD 11.7) years and 13 patients were female. At 6 months, 3 (37.5%) surgical patients and 2 (13.3%) RT patients were deceased. There was a trend showing that surgical patients had worse baseline HRQOL and pain. Pain NRS, EQ-5D, SOSGOQv2.0, and the mental component of the SF-36v2 showed improvement, irrespective of treatment (P>0.05). Ten AEs occurred in the surgical cohort, dominated by wound complications (n=3). Bowel and bladder function improved at 6 weeks in both groups.

Conclusions: Surgical treatment and RT are both valid treatment options for symptomatic sacral metastases. Improvement in HRQOL can be expected with an acceptable AE rate.
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http://dx.doi.org/10.21037/atm.2019.04.88DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595205PMC
May 2019

Predictive Factors for Discharge Destination Following Posterior Lumbar Spinal Fusion: A Canadian Spine Outcome and Research Network (CSORN) Study.

Global Spine J 2019 Jun 29;9(4):403-408. Epub 2018 Aug 29.

McGill University, Montreal, Quebec, Canada.

Study Design: Ambispective cohort study.

Objective: Patients spend on average 3 to 7 days in hospital after lumbar fusion surgery. Patients who are unable to be discharged home may require a prolonged hospital stay while awaiting a bed at a rehabilitation facility, adding cost and imposing a considerable burden on the health care system. Our objective is to identify patient or procedure related predictors of discharge destination for patients undergoing posterior lumbar fusion.

Methods: Analysis of data from the Canadian Spine Outcomes and Research Network. Patients who underwent lumbar fusion for degenerative pathology between 2008 and 2015 were identified. Multivariable logistic regression analysis was used to identify independent predictors of the discharge destination.

Results: A total of 643 patients were identified from the database, 87.1% of the patients (N = 560) were discharged home while 12.9% (N = 83) required discharge to nonhome facilities. Using multivariate logistic regression analysis, the predictors for discharge to a facility rather than home were identified including: increasing age (odds ratio [OR] 1.045, 95% confidence interval [CI] 1.017 -1.075, < .002), increasing body mass index (BMI) (OR 1.069, 95% CI 1.021 -1.118, < .004), increasing disability score (OR 1.025, 95% CI 1.004 -1.046, < .02), living alone preoperatively (OR 1.916, 95% CI 1.004-3.654, < .05), increasing operating time (OR 1.005, 95% CI 1.003 -1.008, < .0001), need for blood transfusion (OR 3.32, 95% CI 1.687-6.528, < .001), and multilevel fusion surgery (OR 1.142, 95% CI 1.007 -1.297, < .04).

Conclusions: Older age, high BMI, living alone, high disability score, extended surgical time, blood transfusion, and multilevel fusion are significant factors that increase the odds of being discharged to facilities other than home.

Level Of Evidence: Level 3.
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http://dx.doi.org/10.1177/2192568218797090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6562215PMC
June 2019

Treatment of Mild Cervical Myelopathy: Factors Associated With Decision for Surgical Intervention.

Spine (Phila Pa 1976) 2019 Nov;44(22):1606-1612

Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia.

Study Design: Prospective Cohort OBJECTIVE.: The aim of this study was to evaluate which demographic, clinical, or radiographic factors are associated with selection for surgical intervention in patients with mild cervical spondylotic myelopathy (CSM).

Summary Of Background Data: Surgery has not been shown superior to best conservative management in mild CSM comparative studies; trials of conservative management represent an acceptable alternative to surgical decompression. It is unknown what patients benefit from surgery.

Methods: This is a prospective study of patients with mild CSM, defined as modified Japanese Orthopaedic Association Score (mJOA) ≥15. Patients were recruited from seven sites contributing to the Canadian Spine Outcomes Research Network. Demographic, clinical, radiographic and health related quality of life data were collected on all patients at baseline. Multivariate logistic regression modeling was used to identify factors associated with surgical intervention.

Results: There were 122 patients enrolled, 105 (86.0%) were treated surgically, and 17 (14.0%) were treated nonoperatively. Overall mean age was 54.8 years (SD 12.6) with 80 (65.5%) males. Bivariate analysis revealed no statistically significant differences between surgical and nonoperative groups with respect to age, sex, BMI, smoking status, number of comorbidities and duration of symptoms; mJOA scores were significantly higher in the nonoperative group (16.8 [SD 0.99] vs. 15.9 [SD 0.89], P < 0.001). There was a statistically significant difference in Neck Disability Index, SF12 Physical Component, SF12 Mental Component Score, EQ5D, and PHQ-9 scores between groups; those treated surgically had worse baseline questionnaire scores (P < 0.05). There was no difference in radiographic parameters between groups. Multivariable analysis revealed that lower quality of life scores on EQ5D were associated with selection for surgical management (P < 0.018).

Conclusion: Patients treated surgically for mild cervical myelopathy did not differ from those treated nonoperatively with respect to baseline demographic or radiographic parameters. Patients with worse EQ5D scores had higher odds of surgical intervention.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003124DOI Listing
November 2019

Decision tree analysis to better control treatment effects in spinal cord injury clinical research.

J Neurosurg Spine 2019 Jun 14:1-9. Epub 2019 Jun 14.

4International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver; and.

Objective: The aim of this study was to use decision tree modeling to identify optimal stratification groups considering both the neurological impairment and spinal column injury and to investigate the change in motor score as an example of a practical application. Inherent heterogeneity in spinal cord injury (SCI) introduces variation in natural recovery, compromising the ability to identify true treatment effects in clinical research. Optimized stratification factors to create homogeneous groups of participants would improve accurate identification of true treatment effects.

Methods: The analysis cohort consisted of patients with acute traumatic SCI registered in the Vancouver Rick Hansen Spinal Cord Injury Registry (RHSCIR) between 2004 and 2014. Severity of neurological injury (American Spinal Injury Association Impairment Scale [AIS grades A-D]), level of injury (cervical, thoracic), and total motor score (TMS) were assessed using the International Standards for Neurological Classification of Spinal Cord Injury examination; morphological injury to the spinal column assessed using the AOSpine classification (AOSC types A-C, C most severe) and age were also included. Decision trees were used to determine the most homogeneous groupings of participants based on TMS at admission and discharge from in-hospital care.

Results: The analysis cohort included 806 participants; 79.3% were male, and the mean age was 46.7 ± 19.9 years. Distribution of severity of neurological injury at admission was AIS grade A in 40.0% of patients, grade B in 11.3%, grade C in 18.9%, and grade D in 29.9%. The level of injury was cervical in 68.7% of patients and thoracolumbar in 31.3%. An AOSC type A injury was found in 33.1% of patients, type B in 25.6%, and type C in 37.8%. Decision tree analysis identified 6 optimal stratification groups for assessing TMS: 1) AOSC type A or B, cervical injury, and age ≤ 32 years; 2) AOSC type A or B, cervical injury, and age > 32-53 years; 3) AOSC type A or B, cervical injury, and age > 53 years; 4) AOSC type A or B and thoracic injury; 5) AOSC type C and cervical injury; and 6) AOSC type C and thoracic injury.

Conclusions: Appropriate stratification factors are fundamental to accurately identify treatment effects. Inclusion of AOSC type improves stratification, and use of the 6 stratification groups could minimize confounding effects of variable neurological recovery so that effective treatments can be identified.
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http://dx.doi.org/10.3171/2019.3.SPINE18993DOI Listing
June 2019
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