Frank X. Pedlow

Long-term results of Phase II study of high dose photon/proton radiotherapy in the management of spine chordomas, chondrosarcomas, and other sarcomas.

Negative surgical margins are uncommon for spine sarcomas; hence, adjuvant radiotherapy (RT) may be recommended but tumor dose may be constrained by spinal cord, nerve, and viscera tolerance.

Total knee arthroplasty for post-traumatic arthrosis

The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 31 knees. The average age at arthroplasty was 60 years old (range, 36-78 years). The interval from fracture to total knee arthroplasty averaged 13 years. Simultaneous corrective osteotomy was necessary in 4 patients to correct axial alignment and preserve ligamentous integrity. Follow-up averaged 46 months. Mean arc of motion increased significantly, from 94 degrees to 100 degrees (P = .027). Average function score improved from 44 to 72 points. This change was statistically significant (P<.0001). Knee Society knee scores also improved significantly, from 36 to 78 points (P<.0001). At most recent follow-up, the functional scores were considered excellent or good in 58%; knee scores were considered excellent or good in 71% of cases. All periarticular osteotomies and tibial tubercle osteotomies healed uneventfully within 16 weeks. Complications occurred in 57% of cases, including aseptic failure (26%), septic failure (10%), patellar tendon rupture (3%), patellar subluxation (6%), thromboembolism (6%), and wound breakdown requiring debridement and muscle flap coverage (6%). Despite significant improvements in motion and function, patients with post-traumatic arthrosis are susceptible to high rates of complications. Adverse outcomes can be minimized by restoring limb alignment, soft tissue balance, and component alignment and by preserving vascularity of the skin and subcutaneous tissues.

Unstable intertrochanteric fracture of the femur : a prospective randomised study comparing anatomical reduction and medial displacement osteotomy

We conducted a prospective randomised trial to compare the results of anatomical reduction and medial displacement osteotomy in 127 consecutive patients with unstable intertrochanteric fractures, of whom 109 completed the study. After an average follow-up of 11 months, we found no significant differences in walking ability, social status or failure of fixation in the two groups. Postoperative complication rates and the early mortality rate were not significantly different, but operating time and blood loss were significantly higher in the osteotomy group. With the use of modern sliding hip screws, medial displacement osteotomy is rarely indicated for unstable intertrochanteric fractures.

High-dose proton-based radiation therapy in the management of spine chordomas: outcomes and clinicopathological prognostic factors.

OBJECT Spinal chordomas can have high local recurrence rates after surgery with or without conventional dose radiation therapy (RT). Treatment outcomes and prognostic factors after high-dose proton-based RT with or without surgery were assessed. METHODS The authors conducted a retrospective review of 126 treated patients (127 lesions) categorized according to disease status (primary vs recurrent), resection (en bloc vs intralesional), margin status, and RT timing. RESULTS Seventy-one sacrococcygeal, 40 lumbar, and 16 thoracic chordomas were analyzed. Mean RT dose was 72.4 GyRBE (relative biological effectiveness). With median follow-up of 41 months, the 5-year overall survival (OS), local control (LC), locoregional control (LRC), and distant control (DC) for the entire cohort were 81%, 62%, 60%, and 77%, respectively. LC for primary chordoma was 68% versus 49% for recurrent lesions (p = 0.058). LC if treated with a component of preoperative RT was 72% versus 54% without this treatment (p = 0.113). Among primary tumors, LC and LRC were higher with preoperative RT, 85% (p = 0.019) and 79% (0.034), respectively, versus 56% and 56% if no preoperative RT was provided. Overall LC was significantly improved with en bloc versus intralesional resection (72% vs 55%, p = 0.016), as was LRC (70% vs 53%, p = 0.035). A trend was noted toward improved LC and LRC for R0/R1 margins and the absence of intralesional procedures. CONCLUSIONS High-dose proton-based RT in the management of spinal chordomas can be effective treatment. In patients undergoing surgery, those with primary chordomas undergoing preoperative RT, en bloc resection, and postoperative RT boost have the highest rate of local tumor control; among 28 patients with primary chordomas who underwent preoperative RT and en bloc resection, no local recurrences were seen. Intralesional and incomplete resections are associated with higher local failure rates and are to be avoided.

Anterior Spinal Arthrodesis With Structural Cortical Allografts and Instrumentation for Spine Tumor Surgery

Study Design. The authors report on anterior vertebral reconstruction following tumor resection with use of fresh-frozen, cortical, long-segment allografts prepared from diaphyseal sections of long bones. A retrospective analysis of clinical outcomes is presented. Objective. To analyze the results following the use of cortical allografts in the treatment of spine tumors. Summary of Background Data. Metastatic disease and primary spinal bone tumors may result in progressive vertebral collapse, instability, deformity, pain, and neurologic deficit. Controversy as to the appropriate type of anterior reconstruction and/or graft material persists. Methods. From 1995 until 2001, 30 patients with primary spinal bone tumors or metastases to the spine were treated by anterior vertebral reconstruction with fresh-frozen cortical bone allografts. Grafts were used in combination with anterior and posterior instrumentation. Results. The median survival was 14 months. Ninety-three percent of all allografts were radiographically incorporated as early as 6 months after surgery in spite of adjuvant chemotherapy and radiation therapy. Fourteen patients (46%) had intraoperative or postoperative complications. Two patients underwent revision surgery for local recurrence. There were no allograft infections, fractures, or collapse. Conclusion. Anterior column reconstruction with structural cortical allografts proved to be a reliable technique in patients with spine tumors. Postoperative complications can often be successfully managed.

Traumatic open anterior lumbosacral fracture dislocation. A report of two cases.

STUDY DESIGN Case presentation. OBJECTIVES To review the diagnosis and treatment of rare anterior lumbosacral fracture dislocations. SUMMARY OF BACKGROUND DATA The severity of closed anterior and open and closed posterior lumbosacral dislocations has been documented; however, there have been no reports of open anterior lumbosacral dislocations in the literature. Two patients are reported who experienced acute open anterior lumbosacral fracture dislocations. METHODS Review of the patient history and physical examination, radiologic review, operative techniques, and a review of the literature. RESULTS Fractures healed in both patients, with no major infections. Both patients had persistent neurologic deficits at last follow-up. CONCLUSIONS Open lumbosacral fracture dislocations are complex injuries that require diligence on the part of the surgeons involved the recognize the severity of the injury, to prevent or resolve any infectious process, to prevent further neurologic injury, and then to obtain and maintain alignment of the spine on the pelvis.

Complications of cervical halo-vest orthoses in elderly patients.

Halo-vest orthoses have been associated with complications. Previous reports have suggested increased complications in elderly patients; however, data are limited. This study reviewed 75 patients =/>65 years with cervical spine fractures treated with halo-vest orthoses. Forty-one patients (55%) experienced at least 1 complication. Pin-site problems were the most frequent adverse outcome. Seventeen patients (23%) had significant pulmonary compromise. Pulmonary complications were associated with high morbidity. We found an 8% early mortality rate. Halo-vest orthoses are useful devises. However, adverse events experienced by elderly patients are common and may lead to significant morbidity and mortality.

Quality of life after en bloc resection of tumors in the mobile spine

BACKGROUND CONTEXT Little has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity. PURPOSE The purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL. STUDY DESIGN This is a retrospective case-control study (Level III). PATIENT SAMPLE Thirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months). OUTCOME MEASURES The outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI). METHODS We performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores. RESULTS We identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL. CONCLUSIONS Patients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Epithelioid hemangioma of the spine: a case series of six patients and review of the literature.

BACKGROUND CONTEXT Epithelioid hemangioma (EH) of bone is a benign vascular tumor that can be locally aggressive. It rarely arises in the spine, and the optimum management of EH of the vertebrae is not well delineated. PURPOSE The report describes our experience treating six patients with EH of the spine in an effort to document the treatment of the rare spinal presentation. STUDY DESIGN This study is designed as a retrospective cohort study. PATIENT SAMPLE A continuous series of patients with the diagnosis of EH of the spine who presented at our institution. OUTCOME MEASURES The clinical and radiographic follow-up of the patient population is documented. METHODS The Bone Sarcoma Registry at our institution was used to obtain a list of all patients diagnosed with EH of the spine. Medical records, radiographs, and pathology reports were retrospectively reviewed in all cases. Only biopsy-proven cases were included. RESULTS The six patients included five men and one woman who ranged in age from 20 to 58 years (with an average age of 40 years). The follow-up available for all six patients ranged from 6 to 115 (average 46.8) months. All patients presented with lytic vertebral body lesions. Five patients presented with pain secondary to their tumor, and the tumor in the sixth patient was found incidentally during the workup for a herniated disc. Three patients required surgical management for instability secondary to the destructive nature of their tumors, and two other patients required emergent decompression secondary to spinal cord compression by the tumor. The sixth patient was treated expectantly after biopsy confirmation. Three patients received postoperative radiation therapy as gross tumor remained after surgery. Three patients had gross total resections and did not receive postoperative radiation. Preoperative embolization was used in four patients. One patient continued to have back pain after surgery and radiation and another continued to have ataxia after surgery and radiation. No tumor locally recurred or progressed. CONCLUSIONS Our data suggest that EH of the spine can be locally aggressive and lead to instability and cord compression. Surgery is required in such instances; however, observation should be considered in patients without instability or cord compression.

Utility of Flexion-Extension Radiographs in Lumbar Spondylolisthesis: A Prospective Study.

Study Design. Prospective cohort study in consecutive patients. Objective. To investigate and compare the use of 2 diagnostic modalities in the evaluation of stability in lumbar spondylolisthesis. Summary of Background Data. Evaluating potential instability in lumbar spondylolisthesis is significant to its management. Lateral lumbar flexion-extension (FE) radiograph is frequently obtained on the basis of a thought that this forward-backward movement can actually describe hypermobility at the listhetic segment. However, simply comparing standard upright lumbar lateral radiograph (U) with a supine sagittal magnetic resonance image (S) (combined, US), something typically conducted for patients with lumbar spondylolisthesis, may also be used. Methods. This prospective study included a cohort of 68 consecutive patients with lumbar spondylolisthesis seen in the outpatient clinic of a single hospital. The mobility observed in US was compared with that observed in FE. The ability to identify “instability” using US was compared with that using FE. In addition, the relationships between mobility determined using FE or US and sex, age, height, weight, body mass index, primary symptom (with or without back pain), nature of spondylolisthesis (degenerative or isthmic), listhetic segment, slippage grade, and focal disc height were examined. Results. Overall, the mobility in US was significantly higher than that in FE (7.68 ± 5.34% vs. 4.90 ± 3.82%, t =−3.545, P = 0.001). The ability to identify “instability” on the basis of US was improved compared with that obtained using FE. Female patients demonstrated higher mobility in FE than male patients to a significant degree. Back pain, isthmic spondylolisthesis, and slippage grade also showed some relevance with mobility but without statistical significance. Conclusion. US may offer an easily available, alternative diagnostic modality in lumbar spondylolisthesis, with the potential of reducing both radiation exposure and costs. Further studies should focus on its influence in clinical decision making. Level of Evidence: 2