Publications by authors named "Ori Barzilai"

71 Publications

Short-segment cement-augmented fixation in open separation surgery of metastatic epidural spinal cord compression: initial experience.

Neurosurg Focus 2021 05;50(5):E11

1Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center; and.

Objective: High-grade metastatic epidural spinal cord compression from radioresistant tumor histologies is often treated with separation surgery and adjuvant stereotactic body radiation therapy. Historically, long-segment fixation is performed during separation surgery with posterior transpedicular fixation of a minimum of 2 spinal levels superior and inferior to the decompression. Previous experience with minimal access surgery techniques and percutaneous stabilization have highlighted reduced morbidity as an advantage to the use of shorter fixation constructs. Cement augmentation of pedicle screws is an attractive option for enhanced stabilization while performing shorter fixation. Herein, the authors describe their initial experience of open separation surgery using short-segment cement-augmented pedicle screw fixation for spinal reconstruction.

Methods: The authors performed a retrospective chart review of patients undergoing open (i.e., nonpercutaneous, minimal access surgery) separation surgery for high-grade epidural spinal cord compression using cement-augmented pedicle screws at single levels adjacent to the decompression level(s). Patient demographics, treatment data, operative complications, and short-term radiographic outcomes were evaluated.

Results: Overall, 44 patients met inclusion criteria with radiographic follow-up at a mean of 8.5 months. Involved levels included 19 thoracic, 5 thoracolumbar, and 20 lumbar. Cement augmentation through fenestrated pedicle screws was performed in 30 patients, and a vertebroplasty-type approach was used in the remaining 14 patients to augment screw purchase. One (2%) patient required an operative revision for a hardware complication. Three (7%) nonoperative radiographic hardware complications occurred, including 1 pathologic fracture at the index level causing progressive kyphosis and 2 incidences of haloing around a single screw. There were 2 wound complications that were managed conservatively without operative intervention. No cement-related complications occurred.

Conclusions: Open posterolateral decompression utilizing short-segment cement-augmented pedicle screws is a viable alternative to long-segment instrumentation for reconstruction following separation surgery for metastatic spine tumors. Studies with longer follow-up are needed to determine the rates of delayed complications and the durability of these outcomes.
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http://dx.doi.org/10.3171/2021.2.FOCUS217DOI Listing
May 2021

Improvement in Quality of Life Following Surgical Resection of Benign Intradural Extramedullary Tumors: A Prospective Evaluation of Patient-Reported Outcomes.

Neurosurgery 2021 04;88(5):989-995

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.

Background: Historically, symptomatic, benign intradural extramedullary (IDEM) spine tumors have been managed with surgical resection. However, minimal robust data regarding patient-reported outcomes (PROs) following treatment of symptomatic lesions exists. Moreover, there are increasing reports of radiosurgical management of these lesions without robust health-related quality of life data.

Objective: To prospectively analyze PROs among patients with benign IDEM spine tumors undergoing surgical resection to define the symptomatic efficacy of surgery.

Methods: Prospective, single-center observational cohort study of patients with benign IDEM spine tumors undergoing open surgical resection. Pre- and postoperative Brief Pain Index (BPI) and MD Anderson Symptom Inventory (MDASI) questionnaires were used to quantitatively assess their symptom control after surgical intervention. Matched pairs were analyzed with the Wilcoxon signed-rank test.

Results: A total of 57 patients met inclusion criteria with both pre- and postoperative PROs. There were 35 schwannomas, 18 meningiomas, 2 neurofibromas, 1 paraganglioma, and 1 mixed schwannoma/neurofibroma. Most patients were American Spinal Injury Association Impairment (ASIA) E (93%) with high-grade spinal cord compression (77%), and underwent either a 2 or 3 level laminectomy (84%). Surgical resection resulted in statistically significant improvement in all 3 composite BPI constructs of pain-severity, pain-interference, and overall patient pain experience (P < .0001). Surgical resection resulted in statistically significant improvements in all composite scores for the MDASI core symptom severity, spine tumor, and disease interference constructs (P < .01). Three patients (5%) had postoperative complications requiring surgical interventions (2 wound revisions and 1 ventriculo-peritoneal shunt).

Conclusion: Surgical resection of IDEM spine tumors provides rapid, significant, and durable improvement in PROs.
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http://dx.doi.org/10.1093/neuros/nyaa561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046588PMC
April 2021

Robotic Resection of a Nerve Sheath Tumor Via a Retroperitoneal Approach.

Oper Neurosurg (Hagerstown) 2021 01;20(2):E85-E90

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

Background: Resection of large nerve sheath tumors in the lumbar spine using minimally invasive approaches is challenging, as approaches to tumors in this region may require facetectomy or partial resection of adjacent ribs for access to the involved neuroforamen and instrumentation across the involved joint to prevent subsequent kyphotic deformity.

Objective: To describe a robot-assisted retroperitoneal approach for resection of a lumbar nerve sheath tumor, obviating the need for facetectomy and instrumentation. The operation is described, together with intraoperative images and an annotated video, in the context of a schwannoma arising from the right L1 root.

Methods: The operation was performed by a urologic surgeon and a neurosurgeon. The patient was placed in lateral position, and the da Vinci Xi robot was used for retroperitoneal access via 5 ports along the right flank. Ultrasound was used to localize the tumor within the psoas. The tumor capsule was defined and released. Encountered nerves were stimulated, allowing small sensory nerves to be identified and safely divided. The tumor was traced into the right L1-L2 neuroforamen and removed.

Results: Complete en bloc resection of the tumor was achieved, including the paraspinal and foraminal components, without any removal of bone and without violation of the dura.

Conclusion: In selected patients, a robot-assisted retroperitoneal approach represents a minimally invasive alternative to traditional approaches for resection of lumbar nerve sheath tumors. This approach obviates the need for bone removal and instrumented spinal fusion. Interdisciplinary collaboration, as well as use of adjunctive technologies, including intraoperative ultrasound and neurophysiologic monitoring, is advised.
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http://dx.doi.org/10.1093/ons/opaa329DOI Listing
January 2021

Survival Trends After Surgery for Spinal Metastatic Tumors: 20-Year Cancer Center Experience.

Neurosurgery 2021 01;88(2):402-412

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

Background: Over the last 2 decades, advances in systemic therapy have increased the expected overall survival for patients with cancer. It is unclear whether the same survival benefit has been conferred to patients requiring surgery for metastatic spinal disease.

Objective: To examine trends in postoperative survival over a 20-yr period for patients surgically treated for spinal metastatic disease.

Methods: Data were obtained for 1515 patients who underwent surgery for metastatic epidural spinal cord compression or tumor-related mechanical instability. Postoperative overall survival was calculated for all included patients using Kaplan-Meier methodology from date of surgery until death or last follow-up for those who were censored. Trends were analyzed using Cox proportional hazards modeling.

Results: Patients with renal, breast, lung, and colon cancers experienced a statistically significant improvement in survival over time based on the year of surgery (40%-100% improvement over the study period), whereas the overall survival trend for the entire cohort did not reach statistical significance (P = .12, median survival 0.71 yr, 95% CI 0.63-0.78). Patients presenting with synchronous metastatic disease had better survival compared to those presenting with metachronous disease (median overall survival: 0.94 vs 0.63 yr, respectively; log-rank P-value = .00001).

Conclusion: The postoperative survival among patients with spinal metastases has improved over the past 20 yr, particularly in patients with kidney, breast, lung, and colon tumors metastatic to the spine. The observed survival improvement emphasizes the need for long-term outcome consideration in treatment decisions for patients undergoing surgery for spinal metastatic tumors.
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http://dx.doi.org/10.1093/neuros/nyaa380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803433PMC
January 2021

Spinal manifestations of Neurofibromatosis type 1.

Childs Nerv Syst 2020 10 20;36(10):2401-2408. Epub 2020 Jun 20.

The Gilbert Israeli International Neurofibromatosis Center (GIINFC), Tel Aviv, Israel.

Background: Neurofibromatosis type 1 (NF1) patients may present a wide spectrum of spinal pathologies. Osseous changes may lead to severe deformities with significant implications on growth and quality of life. Neurogenic tumors and soft tissue abnormalities may cause neuropathic pain and dysfunction ranging from minor paresthesias to profound motor and sensory deficits. Advanced imaging such as whole-body MRI, and volumetric tumor burden assessment have an evolving role in the evaluation and follow-up of patients with high spinal tumor load. Novel biological agents that target the hyperactivated ras pathway are currently under investigation and are reshaping current and future treatment paradigms. Surgical interventions for benign and malignant tumors, as well as deformity correction remain pivotal in treatment frameworks and require careful assessment by a dedicated multidisciplinary team.

Purpose: In this manuscript we review the various spinal manifestations of NF1 patients, indication for surgical intervention and oncological treatments.
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http://dx.doi.org/10.1007/s00381-020-04754-9DOI Listing
October 2020

The Role of Minimal Access Surgery in the Treatment of Spinal Metastatic Tumors.

Global Spine J 2020 Apr 28;10(2 Suppl):79S-87S. Epub 2020 May 28.

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

Study Design: Literature review.

Objective: To provide an overview of the recent advances in minimal access surgery (MAS) for spinal metastases.

Methods: Literature review.

Results: Experience gained from MAS in the trauma, degenerative and deformity settings has paved the road for MAS techniques for spinal cancer. Current MAS techniques for the treatment of spinal metastases include percutaneous instrumentation, mini-open approaches for decompression and tumor resection with or without tubular/expandable retractors and thoracoscopy/endoscopy. Cancer care requires a multidisciplinary effort and adherence to treatment algorithms facilitates decision making, ultimately improving patient outcomes. Specific algorithms exist to help guide decisions for MAS for extradural spinal metastases. One major paradigm shift has been the implementation of percutaneous stabilization for treatment of neoplastic spinal instability. Percutaneous stabilization can be enhanced with cement augmentation for increased durability and pain palliation. Unlike osteoporotic fractures, kyphoplasty and vertebroplasty are known to be effective therapies for symptomatic pathologic compression fractures as supported by high level evidence. The integration of systemic body radiation therapy for spinal metastases has eliminated the need for aggressive tumor resection allowing implementation of MAS epidural tumor decompression via tubular or expandable retractors and preliminary data exist regarding laser interstitial thermal therapy and radiofrequency ablation for tumor control. Neuronavigation and robotic systems offer increased precision, facilitating the role of MAS for spinal metastases.

Conclusions: MAS has a significant role in the treatment of spinal metastases. This review highlights the current utilization of minimally invasive surgical strategies for treatment of spinal metastases.
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http://dx.doi.org/10.1177/2192568219895265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263343PMC
April 2020

Full endoscopic resection of a lumbar osteoblastoma: technical note.

J Neurosurg Spine 2020 Apr 3:1-4. Epub 2020 Apr 3.

Departments of1Neurological Surgery and.

Osteoblastomas are a rare, benign primary bone tumor accounting for 1% of all primary bone tumors, with 40% occurring within the spine. Gross-total resection (GTR) is curative, although depending on location, this can require destabilization of the spine and necessitate instrumented fixation. Through the use of minimally invasive, muscle-sparing approaches, these lesions can be resected while maintaining structural integrity of the spine. The authors present a case report and technical note of a single patient describing the use of a purely endoscopic technique to resect a right L5 superior articulating process osteoblastoma in a 45-year-old woman. The patient underwent an image-guided endoscopic resection of her superior articulating facet osteoblastoma. Intraoperative CT demonstrated GTR. On postoperative examination, she remained neurologically intact with resolution of her pain. At follow-up, she remained pain free. Resection of lumbar osteoblastoma through a fully endoscopic approach was a safe and effective technique in this patient. This technique allowed for GTR without compromising spinal structural integrity, thus eliminating the need for instrumented fixation.
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http://dx.doi.org/10.3171/2020.2.SPINE191091DOI Listing
April 2020

Surgical Management of Intramedullary Spinal Cord Tumors.

Neurosurg Clin N Am 2020 Apr 31;31(2):237-249. Epub 2020 Jan 31.

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, 525 E. 68th St, New York, NY 10065, USA.

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.
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http://dx.doi.org/10.1016/j.nec.2019.12.004DOI Listing
April 2020

Benign Intradural and Paraspinal Nerve Sheath Tumors: Advanced Surgical Techniques.

Neurosurg Clin N Am 2020 Apr 22;31(2):221-229. Epub 2020 Jan 22.

Department of Neurosurgery, Coleman Foundation Comprehensive Spine Tumor Clinic, Rush University Medical Center, 1725 West Harrison Street, Suite 855, Chicago, IL 60612, USA. Electronic address:

Traditional surgical techniques for benign intradural and paraspinal nerve sheath tumors often consisted of open posterior approaches. However, these were limited by the morbidity of open surgery. In addition, iatrogenic instability is often required for total resection of larger or laterally located tumors, thus necessitating the use of additional hardware for spinal fusion. Advances in surgical techniques and technologies have allowed for a plethora of minimally invasive approaches throughout the cervical, thoracic, and lumbar regions. These approaches and their particular applications for the resection of benign peripheral nerve sheath tumors are described, with special attention to modern surgical strategies.
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http://dx.doi.org/10.1016/j.nec.2019.11.002DOI Listing
April 2020

Minimally Invasive Surgery Strategies: Changing the Treatment of Spine Tumors.

Neurosurg Clin N Am 2020 Apr;31(2):201-209

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, 1275 York Avenue, New York, NY 10065, USA. Electronic address:

Innovation in surgical technique and contemporary spinal instrumentation paired with intraoperative navigation/imaging concepts allows for safer and less-invasive surgical approaches. The combination of stereotactic body radiotherapy, contemporary surgical adjuncts, and less-invasive techniques serves to minimize blood loss, soft tissue injury, and length of hospital stay without compromising surgical efficacy, potentially enabling patients to begin adjuvant treatment sooner.
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http://dx.doi.org/10.1016/j.nec.2019.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703710PMC
April 2020

Hybrid Therapy for Spinal Metastases.

Neurosurg Clin N Am 2020 Apr 24;31(2):191-200. Epub 2020 Jan 24.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

The combination of separation surgery and stereotactic body radiotherapy optimizes the treatment of metastatic spine tumors. The integration of SBRT into treatment paradigms produces superb local control rates and consequently has diminished the role of surgery from principle treatment to one of adjuvant therapy. Under this paradigm, hybrid therapy for the treatment of metastatic spine tumors employs separation surgery to decompress the spinal cord and stabilize the spine while creating a safe target for ablative SBRT. Hybrid therapy is well tolerated, allows an early return to systemic therapy, and provides durable, local tumor control compared with more aggressive traditional approaches.
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http://dx.doi.org/10.1016/j.nec.2019.11.001DOI Listing
April 2020

Long-term outcomes of high-dose single-fraction radiosurgery for chordomas of the spine and sacrum.

J Neurosurg Spine 2019 Oct 18:1-10. Epub 2019 Oct 18.

2Neurosurgery.

Objective: The current treatment of chordomas is associated with significant morbidity, high rates of local recurrence, and the potential for metastases. Stereotactic radiosurgery (SRS) as a primary treatment could reduce the need for en bloc resection to achieve wide or marginal margins. Spinal SRS outcomes support the exploration of SRS's role in the durable control of these conventionally radioresistant tumors. The goal of the study was to evaluate outcomes of patients with primary chordomas treated with spinal SRS alone or in combination with surgery.

Methods: Clinical records were reviewed for outcomes of patients with primary chordomas of the mobile spine and sacrum who underwent single-fraction SRS between 2006 and 2017. Radiographic local recurrence-free survival (LRFS), overall survival (OS), symptom response, and toxicity were assessed in relation to the extent of surgery.

Results: In total, 35 patients with de novo chordomas of the mobile spine (n = 17) and sacrum (n = 18) received SRS and had a median post-SRS follow-up duration of 38.8 months (range 2.0-122.9 months). The median planning target volume dose was a 24-Gy single fraction (range 18-24 Gy). Overall, 12 patients (34%) underwent definitive SRS and 23 patients (66%) underwent surgery and either neoadjuvant or postoperative adjuvant SRS. Definitive SRS was selectively used to treat both sacral (n = 7) and mobile spine (n = 5) chordomas. Surgical strategies for the mobile spine were either intralesional, gross-total resection (n = 5) or separation surgery (n = 7) and for the sacrum en bloc sacrectomy (n = 11). The 3- and 5-year LRFS rates were 86.2% and 80.5%, respectively. Among 32 patients (91%) receiving 24-Gy radiation doses, the 3- and 5-year LRFS rates were 96.3% and 89.9%, respectively. The 3- and 5-year OS rates were 90.0% and 84.3%, respectively. The symptom response rate to treatment was 88% for pain and radiculopathy. The extent or type of surgery was not associated with LRFS, OS, or symptom response rates (p > 0.05), but en bloc resection was associated with higher surgical toxicity, as measured using the Common Terminology Criteria for Adverse Events (version 5.0) classification tool, than epidural decompression and curettage/intralesional resection (p = 0.03). The long-term rate of toxicity ≥ grade 2 was 31%, including 20% grade 3 tissue necrosis, recurrent laryngeal nerve palsy, myelopathy, fracture, and secondary malignancy.

Conclusions: High-dose spinal SRS offers the chance for durable radiological control and effective symptom relief with acceptable toxicity in patients with primary chordomas as either a definitive or adjuvant therapy.
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http://dx.doi.org/10.3171/2019.7.SPINE19515DOI Listing
October 2019

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

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

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

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

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

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

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

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

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

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

Study Design: Literature review.

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

Methods: Literature review.

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

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

Image guidance in spine tumor surgery.

Neurosurg Rev 2020 Jun 1;43(3):1007-1017. Epub 2019 Jun 1.

Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.
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http://dx.doi.org/10.1007/s10143-019-01123-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885094PMC
June 2020

Outcome analysis of surgery for symptomatic spinal metastases in long-term cancer survivors.

J Neurosurg Spine 2019 Apr 26:1-6. Epub 2019 Apr 26.

Departments of1Neurosurgery.

OBJECTIVEAs patients with metastatic cancer live longer, an increased emphasis is placed on long-term therapeutic outcomes. The current study evaluates outcomes of long-term cancer survivors following surgery for spinal metastases.METHODSThe study population included patients surgically treated at a tertiary cancer center between January 2010 and December 2015 who survived at least 24 months postoperatively. A retrospective chart and imaging review was performed to collect data regarding patient demographics; tumor histology; type and extent of spinal intervention; radiation data, including treatment dose and field; long-term sequelae, including local tumor control; and reoperations, repeat irradiation, or postoperative kyphoplasty at a previously treated level.RESULTSEighty-eight patients were identified, of whom 44 were male, with a mean age of 61 years. The mean clinical follow-up for the cohort was 44.6 months (range 24.2-88.3 months). Open posterolateral decompression and stabilization was performed in 67 patients and percutaneous minimally invasive surgery in 21. In the total cohort, 84% received postoperative adjuvant radiation and 27% were operated on for progression following radiation. Posttreatment local tumor progression was identified in 10 patients (11%) at the index treatment level and 5 additional patients had a marginal failure; all of these patients were treated with repeat irradiation with 5 patients requiring a reoperation. In total, at least 1 additional surgical intervention was performed at the index level in 20 (23%) of the 88 patients: 11 for hardware failure, 5 for progression of disease, 3 for wound complications, and 1 for postoperative hematoma. Most reoperations (85%) were delayed at more than 3 months from the index surgery. Wound infections or dehiscence requiring additional surgical intervention occurred in 3 patients, all of which occurred more than a year postoperatively. Kyphoplasty at a previously operated level was performed in 3 cases due to progressive fractures.CONCLUSIONSDurable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with limited complications. Complications observed after long-term follow-up include local tumor recurrence/progression, marginal tumor control failures, early or late hardware complications, late wound complications, and progressive spinal instability or deformity.
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http://dx.doi.org/10.3171/2019.2.SPINE181306DOI Listing
April 2019

Spinal Instability Neoplastic Score component validation using patient-reported outcomes.

J Neurosurg Spine 2019 01 18:1-7. Epub 2019 Jan 18.

Departments of1Neurological Surgery and.

OBJECTIVE: The Spinal Instability Neoplastic Score (SINS) correlates with preoperative disability and response to stabilization, with patients with higher scores experiencing greater relief after surgery. However, there is a paucity of data demonstrating the extent to which each component contributes to preoperative clinical status and response to stabilization surgery. The objectives of this study were 2-fold. First, to determine how SINS components correlate with pre- and postoperative patient-reported outcomes (PROs). Second, to determine whether patients with higher SINS (10-12) in the "indeterminate" group respond differently to surgery compared to patients with lower SINS (7-9). METHODS: SINS and PROs were prospectively collected in 131 patients undergoing stabilization surgery for metastatic spinal disease. Association of SINS components and their individual scores with preoperative symptom burden and PRO symptom change after surgery was analyzed using the Spearman rank correlation coefficient (rho) and the Kruskal-Wallis test. SINS and association with preoperative PRO scores and mean differences in post- and preoperative PRO scores were compared for 2 SINS categories within the indeterminate group (7-9 vs 10-12) using the Wilcoxon 2-sample test and Wilcoxon signed-rank test. RESULTS: The presence of mechanical pain, followed by metastatic location, correlated most strongly with preoperative functional disability measures and lower disability PRO scores following surgical stabilization. Blastic rather than lytic bone lesions demonstrated stronger association with pain reduction following stabilization. Following surgery, patients with SINS 10-12 demonstrated markedly greater improvement in pain and disability PRO scores nearly across the board compared to patients with SINS 7-9. CONCLUSIONS: The presence of mechanical pain has the strongest correlation with preoperative disability and improvement in pain and disability PRO scores after surgery. Radiographic components of SINS also correlate with preoperative symptom severity and postoperative PRO, supporting their utilization in evaluation of spinal instability. Among patients with indeterminate SINS, patients with higher scores experience greater reduction in pain and disability PRO scores following surgical stabilization, suggesting that the indeterminate-SINS group includes distinct populations.
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http://dx.doi.org/10.3171/2018.9.SPINE18147DOI Listing
January 2019

Utility of Cement Augmentation via Percutaneous Fenestrated Pedicle Screws for Stabilization of Cancer-Related Spinal Instability.

Oper Neurosurg (Hagerstown) 2019 05;16(5):593-599

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

Background: Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation.

Objective: To evaluate the safety and efficacy of cement augmentation via fenestrated screws.

Methods: A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- <6 mo) and long term (6-12 mo).

Results: Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis.

Conclusion: Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.
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http://dx.doi.org/10.1093/ons/opy186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311793PMC
May 2019

Change in the cross-sectional area of the thecal sac following balloon kyphoplasty for pathological vertebral compression fractures prior to spine stereotactic radiosurgery.

J Neurosurg Spine 2018 10;30(1):111-118

Departments of2Neurosurgery and.

OBJECTIVEPercutaneous vertebral augmentation procedures such as vertebroplasty and kyphoplasty are often performed in cancer patients to relieve mechanical axial-load pain due to pathological collapse deformities. The collapsed vertebrae in these patients can be associated with varying degrees of spinal canal compromise that can be worsened by kyphoplasty. In this study the authors evaluated changes to the spinal canal, in particular the cross-sectional area of the thecal sac, following balloon kyphoplasty (BKP) prior to stereotactic radiosurgery (SRS).METHODSThe authors retrospectively reviewed the records of all patients with symptomatic vertebral compression fractures caused by metastatic disease who underwent kyphoplasty prior to single-fraction SRS. The pre-BKP cross-sectional image, usually MRI, was compared to the post-BKP CT myelogram required for radiation treatment planning. The cross-sectional area of the thecal sac was calculated pre- and postkyphoplasty, and intraprocedural CT imaging was reviewed for epidural displacement of bone fragments, tumor, or polymethylmethacrylate (PMMA) extravasation. The postkyphoplasty imaging was also evaluated for evidence of fracture progression or fracture reduction.RESULTSAmong 30 consecutive patients, 41 vertebral levels were treated with kyphoplasty, and 24% (10/41) of the augmented levels showed a decreased cross-sectional area of the thecal sac. All 10 of these vertebral levels had preexisting epidural disease and destruction of the posterior vertebral body cortex. No bone fragments were displaced posteriorly. Minor epidural PMMA extravasation occurred in 20% (8/41) of the augmented levels but was present in only 1 of the 10 vertebral segments that showed a decreased cross-sectional area of the thecal sac postkyphoplasty.CONCLUSIONSIn patients with preexisting epidural disease and destruction of the posterior vertebral body cortex who are undergoing BKP for pathological fractures, there is an increased risk of further mass effect upon the thecal sac and the potential to alter the SRS treatment planning.
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http://dx.doi.org/10.3171/2018.6.SPINE18206DOI Listing
October 2018

Survival, local control, and health-related quality of life in patients with oligometastatic and polymetastatic spinal tumors: A multicenter, international study.

Cancer 2019 03 29;125(5):770-778. Epub 2018 Nov 29.

Research Department, AOSpine International, Davos, Switzerland.

Background: The treatment of oligometastatic (≤5 metastases) spinal disease has trended toward ablative therapies, yet to the authors' knowledge little is known regarding the prognosis of patients presenting with oligometastatic spinal disease and the value of this approach. The objective of the current study was to compare the survival and clinical outcomes of patients with cancer with oligometastatic spinal disease with those of patients with polymetastatic (>5 metastases) disease.

Methods: The current study was an international, multicenter, prospective study. Patients who were admitted to a participating spine center with a diagnosis of spinal metastases and who underwent surgical intervention and/or radiotherapy between August 2013 and May 2017 were included. Data collected included demographics, overall survival, local control, and treatment information including surgical, radiotherapy, and systemic therapy details. Health-related quality of life (HRQOL) measures included the EuroQOL 5 dimensions 3-level questionnaire (EQ-5D-3L), the 36-Item Short Form Health Survey (SF-36v2), and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

Results: Of the 393 patients included in the current study, 215 presented with oligometastatic disease and 178 presented with polymetastatic disease. A significant survival advantage of 90.1% versus 77.3% at 3 months and 77.0% versus 65.1% at 6 months from the time of treatment was found for patients presenting with oligometastatic disease compared with those with polymetastatic disease. It is important to note that both groups experienced significant improvements in multiple HRQOL measures at 6 months after treatment, with no differences in these outcome measures noted between the 2 groups.

Conclusions: The treatment of oligometastatic disease appears to offer a significant survival advantage compared with polymetastatic disease, regardless of treatment choice. HRQOL measures were found to improve in both groups, demonstrating a palliative benefit for all treated patients.
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http://dx.doi.org/10.1002/cncr.31870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020734PMC
March 2019

Minimal Access Surgery for Spinal Metastases: Prospective Evaluation of a Treatment Algorithm Using Patient-Reported Outcomes.

World Neurosurg 2018 Dec 4;120:e889-e901. Epub 2018 Sep 4.

Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York, New York, USA. Electronic address:

Background: Minimal access surgery (MAS) allows for an early return to systemic and radiation therapy in patients with cancer, leading to its increasing usage in the treatment of spinal metastases. Systematic examination of surgical indications resulted in the development of an algorithm for implementation of MAS in the treatment of spinal metastases. The objective of the present study was to evaluate a spine tumor MAS treatment algorithm using patient-reported outcomes for patients with cancer undergoing treatment of spinal metastases.

Methods: We performed a prospective cohort study of patients who had undergone spinal percutaneous instrumented stabilization with the addition of MAS spinal cord or nerve root decompression and/or kyphoplasty when indicated at a tertiary cancer center from December 2013 to August 2016. Validated patient-reported outcome measures, including the Brief Pain Inventory and the MD Anderson Symptom Inventory-spine module, were used. The patient-reported outcome measures were collected and compared at baseline, 3 months, and long-term follow-up (range, 4.5-12 months).

Results: A total of 51 patients were included. MAS resulted in a statistically significant decrease in the severity of pain and improved activity, ability to work, and enjoyment of life (P < 0.001). The improvement was reported at the short- and long-term follow-up points.

Conclusions: We present our treatment algorithm for MAS implementation in the treatment of thoracolumbar spinal metastases. Prospectively collected data have demonstrated that using this algorithm, MAS surgery for the treatment of spinal metastases results in significant decreases in pain severity and symptom interference with daily activities.
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http://dx.doi.org/10.1016/j.wneu.2018.08.182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786494PMC
December 2018

Hybrid Therapy for Metastatic Epidural Spinal Cord Compression: Technique for Separation Surgery and Spine Radiosurgery.

Oper Neurosurg (Hagerstown) 2019 03;16(3):310-318

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

Background: Despite major advances in radiation and systemic treatments, surgery remains a critical step in the multidisciplinary treatment of metastatic spinal cord tumors.

Objective: To describe the indications, rationale, and technique of "hybrid therapy" (separation surgery and concomitant spine stereotactic radiosurgery [SRS]) along with practical nuances.

Methods: Separation surgery describes a posterolateral approach for circumferential epidural decompression and stabilization. The goal is to decompress the spinal cord, stabilize the spine, and create adequate separation between the neural elements and the tumor for SRS to achieve durable tumor control.

Results: A transpedicular route to achieve ventrolateral access and limited resection of the tumorous vertebral body is carried out. In the setting of high-grade cord compression, caution must be taken when performing the tumor decompression. "Separation" of the ventral epidural tumor component anteriorly creates space for concomitant SRS while a simple laminectomy would not adequately achieve this goal. Dissection of the posterior longitudinal ligament allows maximal ventral decompression. Gross total tumor resection is not crucial for durable tumor control using the "hybrid therapy" model. Thus, attempts at ventral tumor resection may unnecessarily increase operative morbidity. Cement augmentation of the construct or vertebral body may improve construct stability. CT myelogram is the preferred exam for postoperative SRS planning. Radiosurgical planning constitutes a multidisciplinary effort and guidelines for contouring in the postoperative setting have recently become available.

Conclusion: Separation surgery is an effective, well-tolerated, and reproducible surgery. It provides safe margins for concomitant SRS. Combined, this "Hybrid Therapy" allows durable local control, maintenance of spinal stability, and palliation of symptoms, while minimizing operative morbidity.
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http://dx.doi.org/10.1093/ons/opy137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189205PMC
March 2019

Current Role of Uninstrumented Lumbar Fusion.

Authors:
Ori Barzilai

World Neurosurg 2018 07 19;115:509-511. Epub 2018 May 19.

Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2018.05.063DOI Listing
July 2018

Hybrid surgery-radiosurgery therapy for metastatic epidural spinal cord compression: A prospective evaluation using patient-reported outcomes.

Neurooncol Pract 2018 May 22;5(2):104-113. Epub 2017 Jul 22.

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

Background: Patient-reported outcomes (PRO) represent an important measure of cancer therapy effect. For patients with metastatic epidural spinal cord compression (MESCC), hybrid therapy using separation surgery and stereotactic radiosurgery preserves neurologic function and provides tumor control. There is currently a paucity of data reporting PRO after such combined modality therapy for MESCC. Delineation of hybrid surgery-radiosurgery therapy effect on PRO validates the hybrid approach as an effective therapy resulting in meaningful symptom relief.

Patients And Methods: Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP), PROs validated in the cancer population, were prospectively collected. Patients with MESCC who underwent separation surgery followed by stereotactic radiosurgery were included. Separation surgery included a posterolateral approach without extensive cytoreductive tumor excision. A median postoperative radiosurgery dose of 2700 cGy was delivered. The change in PRO 3 months after the hybrid therapy represented the primary study outcome. Preoperative and postoperative evaluations were analyzed using the Wilcoxon signed-rank test for matched pairs.

Results: One hundred eleven patients were included. Hybrid therapy resulted in a significant reduction in the BPI items "worst" and "right now" pain ( < .0001), and in all BPI constructs (severity, interference with daily activities, and pain experience, < .001). The MDASI-SP demonstrated reduction in spine-specific pain severity and interference with general activity ( < .001), along with decreased symptom interference ( < .001).

Conclusions: Validated PRO instruments showed that in patients with MESCC, hybrid therapy with separation surgery and radiosurgery results in a significant decrease in pain severity and symptom interference. These prospective data confirm the benefit of hybrid therapy for treatment of MESCC and should facilitate referral of patients with MESCC for surgical evaluation.
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http://dx.doi.org/10.1093/nop/npx017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946922PMC
May 2018

Improvement in cognitive function after surgery for low-grade glioma.

J Neurosurg 2018 Mar 1:1-9. Epub 2018 Mar 1.

OBJECTIVECognition is a key component in health-related quality of life (HRQoL) and is currently incorporated as a major parameter of outcome assessment in patients treated for brain tumors. The effect of surgery on cognition and HRQoL remains debatable. The authors investigated the impact of resection of low-grade gliomas (LGGs) on cognition and the correlation with various histopathological markers.METHODSA retrospective analysis of patients with LGG who underwent craniotomy for tumor resection at a single institution between 2010 and 2014 was conducted. Of 192 who underwent resective surgery for LGG during this period, 49 had complete pre- and postoperative neurocognitive evaluations and were included in the analysis. These patients completed a full battery of neurocognitive tests (memory, language, attention and working memory, visuomotor organization, and executive functions) pre- and postoperatively. Tumor and surgical characteristics were analyzed, including volumetric measurements and histopathological markers (IDH, p53, GFAP).RESULTSPostoperatively, significant improvement was found in memory and executive functions. A subgroup analysis of patients with dominant-side tumors, most of whom underwent intraoperative awake mapping, revealed significant improvement in the same domains. Patients whose tumors were on the nondominant side displayed significant improvement only in memory functions. Positive staining for p53 testing was associated with improved language function and greater extent of resection in dominant-side tumors. GFAP positivity was associated with improved memory in patients whose tumors were on the nondominant side. No correlation was found between cognitive outcome and preoperative tumor volume, residual volume, extent of resection, or IDH1 status.CONCLUSIONSResection of LGG significantly improves memory and executive function and thus is likely to improve functional outcome in addition to providing oncological benefit. GFAP and pP53 positivity could possibly be associated with improved cognitive outcome. These data support early, aggressive, surgical treatment of LGG.
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http://dx.doi.org/10.3171/2017.9.JNS17658DOI Listing
March 2018

State of the Art Treatment of Spinal Metastatic Disease.

Neurosurgery 2018 06;82(6):757-769

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

Treatment paradigms for patients with spine metastases have evolved significantly over the past decade. Incorporating stereotactic radiosurgery into these paradigms has been particularly transformative, offering precise delivery of tumoricidal radiation doses with sparing of adjacent tissues. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional radiation. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive, techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care, improving both local control and patient survivals. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists, and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases, integrating these data into a decision framework, NOMS, which integrates the 4 sentinel decision points in metastatic spine tumors: Neurologic, Oncologic, Mechanical stability, and Systemic disease and medical co-morbidities.
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http://dx.doi.org/10.1093/neuros/nyx567DOI Listing
June 2018

Predictors of quality of life improvement after surgery for metastatic tumors of the spine: prospective cohort study.

Spine J 2018 07 6;18(7):1109-1115. Epub 2017 Nov 6.

Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York, NY, USA. Electronic address:

Background Context: Surgical decompression and stabilization followed by radiosurgery represents an effective method for local tumor control and neurologic preservation for patients with metastatic epidural spinal cord compression (MESCC). We have previously demonstrated improvement in health-related quality of life (HrQOL) after this combined modality treatment ("hybrid therapy").

Purpose: The current analysis focuses on delineation of patient-specific prognostic factors predictive of HrQOL change after combined surgery-stereotactic radiosurgery (SRS) treatment of MESCC.

Study Design: This is a prospective, single-center, cohort study.

Patient Sample: One hundred and eleven patients with MESCC who underwent separation surgery followed by SRS were included.

Outcome Measures: Prognostic factors associated with improved patient-reported outcome (PRO) measures.

Methods: Patient-reported outcome tools, that is, Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP), both validated in the cancer population, were prospectively collected. Numeric prognostic factors were correlated with PRO measures using the Spearman rank correlation coefficient. Categorical prognostic factors were correlated with PRO measures using the Wilcoxon two-sample test (for two categories) or the Kruskal-Wallis test (for three or more categories). All statistical tests were two-sided with a level of significance <.05 for correlation of prognostic factors with PRO constructs and a level of significance <.0014 for correlation of prognostic factors with PRO items. Statistical analyses were done in SAS (version 9.4, Cary, NC, USA).

Results: One hundred and eleven patients were included in this analysis. Patients with lower preoperative Medical Research Council (MRC) motor scores experienced a greater decrease in symptom interference (BPI interference construct (p=.03) and individual functional measures including general activity (p=.001), walking (p=.001), and normal work (p=.006)). Lumbar location was associated with better outcomes than cervical or thoracic as noted on the BPI pain experience construct (p=.03) and MDASI-SP interference (p=.01) and core symptom (p=.002) constructs. Patients with American Spinal Injury Association (ASIA) scores of C or D benefit more than those with ASIA E on BPI interference construct (p=.04). Patients with higher Eastern Cooperative Oncology Group (ECOG) scores at presentation benefit more than those with low ECOG scores on MDASI-SP interference construct (p=.03). Women benefit more than men on BPI interference (p=.03) and pain experience (p=.04) constructs. Patients with prior spinal surgery at the current level of interest benefit less than those who are naïve surgical patients in MDASI-SP interference construct (p=.04).

Conclusions: Delineation of patient characteristics associated with HrQOL improvement provides crucial information for patient selection, patient education, and setting treatment expectations. For patients with MESCC treated with hybrid therapy using surgery and radiosurgery, the presence of neurologic deficits and diminished performance status, lumbar tumor level, and female gender were associated with greater PRO improvement.
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http://dx.doi.org/10.1016/j.spinee.2017.10.070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5936646PMC
July 2018

Safety and utility of kyphoplasty prior to spine stereotactic radiosurgery for metastatic tumors: a clinical and dosimetric analysis.

J Neurosurg Spine 2018 01 3;28(1):72-78. Epub 2017 Nov 3.

Departments of1Neurosurgery.

OBJECTIVE The aim of this study was to evaluate the safety and efficacy of kyphoplasty treatment prior to spine stereotactic radiosurgery (SRS) in patients with spine metastases. METHODS A retrospective review of charts, radiology reports, and images was performed for all patients who received SRS (single fraction; either standalone or post-kyphoplasty) at a large tertiary cancer center between January 2012 and July 2015. Patient and tumor variables were documented, as well as treatment planning data and dosimetry. To measure the photon scatter due to polymethyl methacrylate, megavolt photon beam attenuation was determined experimentally as it passed through a kyphoplasty cement phantom. Corrected electron density values were recalculated and compared with uncorrected values. RESULTS Of 192 treatment levels in 164 unique patients who underwent single-fraction SRS, 17 (8.8%) were treated with kyphoplasty prior to radiation delivery to the index level. The median time from kyphoplasty to SRS was 22 days. Four of 192 treatments (2%) demonstrated local tumor recurrence or progression at the time of analysis. Of the 4 local failures, 1 patient had kyphoplasty prior to SRS. This recurrence occurred 18 months after SRS in the setting of widespread systemic disease and spinal tumor progression. Dosimetric review demonstrated a lower than average treatment dose for this case compared with the rest of the cohort. There were no significant differences in dosimetry analysis between the group of patients who underwent kyphoplasty prior to SRS and the remaining patients in the cohort. A preliminary analysis of polymethyl methacrylate showed that dosimetric errors due to uncorrected electron density values were insignificant. CONCLUSIONS In cases without epidural spinal cord compression, stabilization with cement augmentation prior to SRS is safe and does not alter the efficacy of the radiation or preclude physicians from adhering to SRS planning and contouring guidelines.
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http://dx.doi.org/10.3171/2017.5.SPINE1746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274655PMC
January 2018
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