Jacob A. Miller

The impact of preoperative depression on quality of life outcomes after lumbar surgery

BACKGROUND CONTEXT Some, smaller studies have investigated the effect of preoperative depression on postoperative improvement in quality of life (QOL). However, they have not used the Patient Health Questionnaire 9 (PHQ-9) in self-reported depression. PURPOSE To assess the effect of preoperative depression as measured by the PHQ-9 on postoperative improvement in QOL. STUDY DESIGN A retrospective review at a single tertiary-care referral center. PATIENT SAMPLE Patients who underwent lumbar decompression or fusion between 2008 and 2012. OUTCOMES MEASURES A self-reported EuroQol five-dimensions (EQ-5D) quality-adjusted life-years Index. METHODS Quality of life data were collected using the institutional prospectively collected database of patient-reported health status measures. The EQ-5D questionnare, PDQ, and PHQ-9 were used. Linear and logistic regression analyses were performed to assess the impact of preoperative depression on QOL improvement. RESULTS Elevated preoperative pain (PDQ, β=-0.0017, p=.0009) and worsened depression (PHQ-9, β=-0.0044, p=.0359) were significantly associated with diminished postoperative improvement in QOL, as measured by the EQ-5D. Furthermore, greater depression (PHQ-9, odds ratio [OR] 0.93, p<.0001) and pain (PDQ, OR 0.99, p=.02) were associated with significantly diminished postoperative improvement exceeding the minimum clinically important difference. CONCLUSIONS Increased preoperative pain and depression were shown to be associated with significantly reduced improvement in postoperative QOL, as measured by the EQ-5D.

The impact of preoperative depression on quality of life outcomes after posterior cervical fusion.

BACKGROUND CONTEXT Posterior cervical fusion (PCF) has been shown to be an effective treatment for cervical spondylosis, but is associated with a 9% complication rate and high costs. To limit such complications and costs, it is imperative that proper selection of surgical candidates occur for those most likely to do well with the surgery. Affective disorders, such as depression, are associated with worsened outcomes after lumbar surgery; however, this effect has not been evaluated in patients undergoing cervical spine surgery. PURPOSE To assess the predictive value of preoperative depression and the health state on 1-year quality of life (QOL) outcomes after PCF. STUDY DESIGN A retrospective cohort analysis. PATIENT SAMPLE Eighty-eight patients who underwent PCF for cervical spondylosis were reviewed. OUTCOME MEASURES Preoperative and 1-year postoperative health outcomes were assessed based on the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire-9 (PHQ-9), and the EuroQol five-dimensions (EQ-5D) questionnaire. METHODS Univariable and multivariable regression analyses were performed to assess for preoperative predictors of 1-year change in health status. RESULTS Compared with preoperative health states, the PCF cohort showed statistically significant improved PDQ (87.8 vs. 73.6), PHQ-9 (7.7 vs. 6.6), and EQ-5D (0.50 vs. 0.60) scores at 1 year postoperatively. Only 10/88 (11%) patients achieved or surpassed the minimum clinically important difference for the PHQ-9 (5). Multiple linear and logistic regression analyses showed that increasing PHQ-9 and EQ-5D preoperative scores were associated with reduced 1-year postoperative improvement in health status (EQ-5D index). CONCLUSIONS Of patients who undergo PCF, those with a greater degree of preoperative depression have lower improvements in postoperative QOL compared with those with less depression. Additionally, patients with better preoperative health states also attain lower 1-year QOL improvements.

Spine Stereotactic Radiosurgery With Concurrent Tyrosine Kinase Inhibitors for Metastatic Renal Cell Carcinoma

OBJECT Systemic control of metastatic renal cell carcinoma (mRCC) has substantially improved with the development of VEGF, mTOR, and checkpoint inhibitors. The current first-line standard of care is a VEGF tyrosine kinase inhibitor (TKI). In preclinical models, TKIs potentiate the response to radiotherapy. Such improved efficacy may prolong the time to salvage therapies, including whole-brain radiotherapy or second-line systemic therapy. As the prevalence of mRCC has increased, the utilization of spine stereotactic radiosurgery (SRS) has also increased. However, clinical outcomes following concurrent treatment with SRS and TKIs remain largely undefined. The purpose of this investigation was to determine the safety and efficacy of TKIs when delivered concurrently with SRS. The authors hypothesized that first-line TKIs delivered concurrently with SRS significantly increase local control compared with SRS alone or TKIs alone, without increased toxicity. METHODS A retrospective cohort study of patients undergoing spine SRS for mRCC was conducted. Patients undergoing SRS were divided into 4 cohorts: those receiving concurrent first-line TKI therapy (A), systemic therapy-naïve patients (B), and patients who were undergoing SRS with (C) or without (D) concurrent TKI treatment after failure of first-line therapy. A negative control cohort (E) was also included, consisting of patients with spinal metastases managed with TKIs alone. The primary outcome was 12-month local failure, defined as any in-field radiographic progression. Multivariate competing risks regression was used to determine the independent effect of concurrent first-line TKI therapy upon local failure. RESULTS One hundred patients who underwent 151 spine SRS treatments (232 vertebral levels) were included. At the time of SRS, 46% were receiving concurrent TKI therapy. In each SRS cohort, the median prescription dose was 16 Gy in 1 fraction. Patients in Cohort A had the highest burden of epidural disease (96%, p < 0.01). At 12 months, the cumulative incidence of local failure was 4% in Cohort A, compared with 19%-27% in Cohorts B-D and 57% in Cohort E (p < 0.01). Multivariate competing risks regression demonstrated that concurrent first-line TKI treatment (Cohort A) was independently associated with a local control benefit (HR 0.21, p = 0.04). In contrast, patients treated with TKIs alone (Cohort E) experienced an increased rate of local failure (HR 2.43, p = 0.03). No toxicities of Grade 3 or greater occurred following SRS with concurrent TKI treatment, and the incidence of post-SRS vertebral fracture (overall 21%) and pain flare (overall 17%) were similar across cohorts. CONCLUSIONS The prognosis for patients with mRCC has significantly improved with TKIs. The present investigation suggests a local control benefit with the addition of concurrent first-line TKI therapy to spine SRS. These results have implications in the oligometastatic setting and support a body of preclinical radiobiological research.

Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery.

Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery An estimated 158 000 surgical site infections (SSIs) occur in the Unites States annually, at a cost of

The Impact of Socioeconomic Status on the Utilization of Spinal Imaging.

3.45 billion to

Radiologic and clinical characteristics of vertebral fractures in multiple myeloma

10.07 billion.1,2 Investigations have demonstrated the efficacy of infection prevention bundles in reducing SSIs across multiple surgical specialties.3,4 Neurosurgical SSIs incur the highest costs, and spine surgeries account for more than 1.01 million procedures annually, presenting an opportunity for reducing health care–related harm and expenditures.5 We hypothesized that implementation of an infection prevention bundle would be associated with a reduction in SSIs and disease-specific costs.

Stereotactic Radiosurgery for the Treatment of Primary and Metastatic Spinal Sarcomas

BACKGROUND Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.

Overall survival and the response to radiotherapy among molecular subtypes of breast cancer brain metastases treated with targeted therapies

BACKGROUND CONTEXT Nearly 80% of patients with newly diagnosed multiple myeloma (MM) have bony lesions on magnetic resonance imaging (MRI). These lesions may progress to debilitating vertebral fractures. No studies have quantitatively characterized these fractures or identified predictors of fracture burden and severity. PURPOSE The purpose of this study was to characterize the clinical and radiologic features of these fractures and to identify independent predictors of fracture burden and severity. STUDY DESIGN/SETTING A consecutive retrospective chart review was conducted from January 2007 to December 2013 at a single tertiary-care institution. PATIENT SAMPLE Patients with diagnoses of both MM and vertebral fracture were included in this study. Those with a history of non-MM vertebral fracture were excluded. OUTCOME MEASURES The primary outcome measure was height loss of the fractured vertebral body, whereas secondary outcome measures included number of fractures and morphology. METHODS Data were collected at fracture presentation. Radiologic data were obtained from T1-weighted MRI. Anterior, middle, and posterior vertebral body height losses were recorded, and a Genant grading was made. Multivariable Poisson and logistic regression were performed to identify predictors of fracture burden and severity. RESULTS Among 50 patients presenting with vertebral fracture, 124 fractures were observed. The majority (76%) of these patients did not have a previous MM diagnosis. The most common presenting symptom was back pain (84%), followed by neurologic (54%) and constitutional (50%) symptoms. The mean anterior, middle, and posterior height losses of the fractured vertebral body were 30%, 37%, and 16%, respectively. Twenty percent of fractures were Genant Grade 1 (mild), whereas 32% and 48% were grades 2 (moderate) and 3 (severe). Fifty-five percent of fractures were biconcave, whereas 32% and 13% were wedge and crush fractures. Lower body mass index and albumin and increased myeloma protein, light chains, and creatinine predicted an increased number of fractures at presentation. Increased β2-microglobulin and creatinine predicted more severe vertebral fractures. CONCLUSIONS In the present study, 124 fractures were observed among 50 patients. These fractures were generally severe, biconcave, and in the thoracic spine. Laboratory signs of advanced MM predict greater fracture burden and severity. In the future, monitoring of these predictors may raise suspicion for an MM-associated vertebral fracture.

Melanoma brain metastasis: the impact of stereotactic radiosurgery, BRAF mutational status, and targeted and/or immune-based therapies on treatment outcome

Purpose: Despite advancements in local and systemic therapy, metastasis remains common in the natural history of sarcomas. Unfortunately, such metastases are the most significant source of morbidity and mortality in this heterogeneous disease. As a classically radioresistant histology, stereotactic radiosurgery has emerged to control spinal sarcomas and provide palliation. However, there is a lack of data regarding pain relief and relapse following stereotactic radiosurgery. Methods: We queried a retrospective institutional database of patients who underwent spine stereotactic radiosurgery for primary and metastatic sarcomas. The primary outcome was pain relief following stereotactic radiosurgery. Secondary outcomes included progression of pain, radiographic failure, and development of toxicities following treatment. Results: Forty treatment sites were eligible for inclusion; the median prescription dose was 16 Gy in a single fraction. Median time to radiographic failure was 14 months. At 6 and 12 months, radiographic control was 63% and 51%, respectively. Among patients presenting with pain, median time to pain relief was 1 month. Actuarial pain relief at 6 months was 82%. Median time to pain progression was 10 months; at 12 months, actuarial pain progression was 51%. Following multivariate analysis, presence of neurologic deficit at consult (hazard ratio: 2.48, P < .01) and presence of extraspinal bone metastases (hazard ratio: 2.83, P < .01) were associated with pain relief. Greater pain at consult (hazard ratio: 1.92, P < .01), prior radiotherapy (hazard ratio: 4.65, P = .02), and greater number of irradiated vertebral levels were associated with pain progression. Conclusions: Local treatment of spinal sarcomas has remained a challenge for decades, with poor rates of local control and limited pain relief following conventional radiotherapy. In this series, pain relief was achieved in 82% of treatments at 6 months, with half of patients experiencing pain progression by 12 months. Given minimal toxicity and suboptimal pain control at 12 months, dose escalation beyond 16 Gy is warranted.

The impact of diabetes upon quality of life outcomes after lumbar decompression.

The current study was conducted to investigate survival and the response to radiotherapy among patients with molecular subtypes of breast cancer brain metastases treated with or without targeted therapies.