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Abstract BACKGROUND Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care. OBJECTIVE To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis. METHODS A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity. RESULTS Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity. CONCLUSION In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates. Graphical Abstract Graphical Abstract

Abstract BACKGROUND: Adjacent segment disease (ASD) development is known to occur after anterior cervical discectomy and fusion (ACDF). OBJECTIVE: To study the relationship between index ACDF levels and the location of ASD development (above/below), as well as the effect of fusion length on ASD development. METHODS: We report 888 patients who underwent ACDF for cervical spondylosis over a twenty-year period at a single institution. Of these patients, 108 had re-do surgery due to symptomatic ASD. Patients were followed for an average of 92.4 ± 52.6 months after the index ACDF. RESULTS: In agreement with previous ACDF case series, we found the highest rates of cervical spinal degenerative disease requiring surgery at C5/C6, followed by C6/C7. Interestingly, neither the inherent location of index ACDF nor the length of instrumented arthrodesis appeared to correlate with the propensity to develop ASD. However, patients were more likely to develop ASD above the index level of fusion. This was true even for patients undergoing a second revision surgery due to recurrent ASD. Importantly, our data are consistent with existing in vitro biomechanical data in cadaveric spines. CONCLUSION: We describe in detail the location and length of arthrodesis for index ACDFs, as well as first and second revision fusion surgeries in one of the largest Western cohorts in the literature. Our findings support the theory that iatrogenically introduced stress and instability at adjacent spinal segments contribute to the pathogenesis of ASD.

While the abscopal effect has been previously described, the phenomenon has been poorly defined in the case of spinal metastases. This article is unique in that we present the first systematic review of the abscopal effect after radiation therapy to metastatic spinal cancer, especially since the spinal column represents one of the most common metastatic locations. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) resources, a systematic review identified relevant studies via a computer-aided search of MEDLINE and Embase. Ten publications that met the inclusion and exclusion criteria from the PRISMA flow diagram described a total of 13 patients, 76.9% of whom demonstrated image findings of the abscopal effect. In summary, important trends in the nine patients who experienced the abscopal effect in this review include higher doses of radiation and treatment with immunomodulators, both of which may help guide treatment paradigms for spinal metastases superimposed on diffuse metastatic disease. These trends, however, still warrant further investigations with experimental and clinical studies for a mechanistic understanding of the abscopal effect.

•Spondylolisthesis improved by 13% after PLF+PLIF/TLIF vs 5% after PLF (p<0.001).•Interbody fusions were less likely to undergo reoperation compared to non-interbody.•Non-interbody fusion was strongest reoperation predictor for degenerative disease. Posterior or transforaminal lumbar interbody fusions (PLIF/TLIF) may improve the outcomes in patients with lumbar spondylolisthesis. This study aims to compare outcomes after posterolateral fusion (PLF) only versus PLF with interbody fusion (PLF+PLIF/TLIF) in patients with spondylolisthesis. We retrospectively reviewed103 patients who underwent first-time instrumented lumbar fusions for degenerative or isthmic spondylolisthesis. Anterior techniques and multilevel interbody fusions were excluded. All patients were followed for at least 2 years postoperatively. Clinical outcomes including back pain, radiculopathy, weakness, sensory deficits, and loss of bowel/bladder function were ascertained from clinic notes. Radiographic measures were calculated with Tillard percentage of spondylolisthesis. Reoperation for progression of degenerative disease, a primary endpoint, was indicated for all patients with (1) persistent or new-onset neurological symptoms; and (2) radiographic imaging that correlated with clinical presentation. Of the 103 patients, 56.31% were managed with PLF and 43.69% with PLF+PLIF/TLIF. On radiographic studies, spondylolisthesis improved by a mean of 13.06% after PLF+PLIF/TLIF versus 5.67% after PLF (p<0.001). In comparison to PLF+PLIF/TLIF, patients undergoing PLF experienced higher rates of postoperative improvement in back pain, sensory deficits, motor weakness, radiculopathy, and bowel/bladder difficulty; however, these differences did not reach statistical significance. The PLF cohort had a significantly higher incidence of reoperation (p=0.011) and pseudoarthrosis/instrumentation failure (p=0.043). In the logistical analyses, non-interbody fusion was the strongest predictor of reoperation for progression of degenerative disease. Compared to PLF only, PLF+PLIF/TLIF were statistically significantly associated with a greater correction of spondylolisthesis. Patients with interbody fusions were less likely to undergo reoperation for degenerative disease progression compared to non-interbody fusions. However, greater listhesis correction and decreased reoperation in the PLF+PLIF/TLIF cohort should be weighed with favorable clinical outcomes in the PLF cohort.

Traumatic pneumocephaly is literally defined as ‘air in the head’ after trauma. While this phenomenon has been well described in the literature, our case report is unique in describing diffuse pneumocephalus in the subaponeurotic space, subdural space, subarachnoid space, brain and ventricles without a break in the cranial vault: a 26-year-old man fell from a =9 meter scaffolding in a water tower. Following an arduous and delayed extrication, the patient was unresponsive with loss of pulse requiring intubation, cardiopulmonary resuscitation and release of tension pneumothorax with bilateral thoracostomy tubes. Examination remained poor with a Glasgow Coma Scale of 3. Immediate exploratory laparotomy was performed for a small right retroperitoneal haematoma on Focused Assessment with Sonography for Trauma. Postoperative imaging revealed diffuse pneumocephaly without facial fractures. This case presentation explores unusual causes of fistulous connections with the atmosphere that may lead to air trapped in and around the cranial vault.

A 47-year-old woman with a history of anaemia presented to the emergency room with an acute onset of leg weakness. Physical examination of the bilateral lower extremities was significant for 0/5 muscle strength in all muscle groups with decreased pinprick and temperature sensation. A sensory level at the umbilicus was appreciated. Fine touch and proprioception were preserved. Bowel and bladder function were intact. CT revealed several thoracic, vertebral haemangiomatas. An MRI was suggestive of an epidural clot at the T8–T10-weighted posterior epidural space. At the level of the lesion, the cerebrospinal fluid space was completely effaced, and the flattened spinal cord exhibited signs of oedema and compressive myelopathy. The patient immediately underwent surgical decompression of the spinal cord. An epidural clot and vessel conglomeration were identified. A postoperative spinal angiogram confirmed the diagnosis of vertebral haemangioma. At 1-month follow-up, the patient regained strength and sensation.

Abstract BACKGROUND Despite a proven superior efficacy of prophylactic low-molecular-weight heparin (LMWH) over unfractionated heparin (UFH) in the majority of surgical specialties, chemoprophylactic techniques after spine surgery have not been established because of the fear of epidural hematomas with LMWH. OBJECTIVE To determine the efficacy of LMWH vs UFH in the prevention of venous thromboembolism (VTE) events, balanced against the risk of epidural hematoma. METHODS This is the first matched cohort design that directly compares prophylactic LMWH to UFH after spine surgery for degenerative/deformity pathologies at a tertiary academic center. Prospectively collected patients receiving prophylactic LMWH and a historical cohort of patients receiving prophylactic UFH (prior to 2017) were matched in 1:1 ratio based on age ±5 yr, American Society of Anesthesiologists classification, location in the spinal column, and type of surgery. RESULTS Of 562 patients, VTE events equaled 1.4% (n = 8): 1.4% (n = 4) with LMWH was exactly equal to 1.4% (n = 4) with UFH. Epidural hematomas reached 0.8% (n = 5): 1.4% (n = 4) with UFH vs 0.3% (n = 1) with the LMWH (P = .178). Utilizing adjusted odds ratio (ORadj), the type of chemoprophylaxis after spine surgery failed to predict VTE events. Similarly, the chemoprophylactic technique failed to predict epidural hematoma in the multivariable regression analysis, although UFH trended toward a higher complication rate (ORadj = 3.15 [0.48-20.35], P = .227). CONCLUSION Chemoprophylactic patterns failed to predict VTE. Although no differences in epidural hematoma rates were detected, our analysis does highlight a trend toward a safer profile with LMWH vs UFH. LMWH may be a safe alternative to UFH in spine surgery.

Abstract BACKGROUND Previous studies have failed to demonstrate statistically significant differences in postsurgical outcomes between operative cases featuring resident participation compared to attending only; however, the effects of level of postgraduate year (PGY) training have not been explored. OBJECTIVE To correlate different PGYs in neurosurgery with 30-d postoperative outcomes. METHODS Using National Surgical Quality Improvement Program 2005–2014, adult neurosurgical cases were divided into subspecialties: spine, open-vascular, cranial, and functional in teaching institutions. Comparison groups: cases involving junior residents (PGY 1–PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Primary outcome measures included any wound disruption (surgical site infections and/or wound dehiscence), Clavien-Dindo grade IV (life-threatening) complications, and death. RESULTS Compared to junior residents (n = 3729) and mid-level residents (n = 2779), senior residents (n = 3692) operated on patients with a greater comorbidity burden, as reflected by higher American Society of Anesthesiology classifications and decreased level of functional status. Cases with senior resident participation experienced the highest percentages of postoperative wound complications (P = .005), Clavien-Dindo grade IV complications (P = .001), and death (P = .035). However, following multivariable regression, level of residency training in neurosurgery did not predict any of the 3 primary outcome measures. Compared to spinal cases, cranial cases predicted a higher incidence of life-threatening complications (odds ratio 1.84, P < .001). CONCLUSION Cases in the senior resident cohort were more technically challenging and exhibited a higher comorbidity burden preoperatively; however, level of neurosurgical training did not predict any wound disruption, life-threatening complications, or death. Residents still provide safe and effective assistance to attending neurosurgeons.