Kathryn Hess

How Does the Level of Sacral Resection for Primary Malignant Bone Tumors Affect Physical and Mental Health, Pain, Mobility, Incontinence, and Sexual Function?

BackgroundEn bloc resection for treatment of sacral tumors is the approach of choice for patients with resectable tumors who are well enough to undergo surgery, and studies describe patient survival, postoperative complications, and recurrence rates associated with this treatment. However, most of these studies do not provide patient-reported functional outcomes other than binary metrics for bowel and bladder function postresection.Questions/purposesThe purpose of this study was to use validated patient-reported outcomes tools to compare quality of life based on level of sacral resection in terms of (1) physical and mental health; (2) pain; (3) mobility; and (4) incontinence and sexual function.MethodsOur analysis included 33 patients (19 men, 14 women) who had a mean age of 53 years (range, 22–72 years) with a quality-of-life survey administered at a mean postoperative followup of 41 months (range, 6–123 months). The majority of patient-reported quality-of-life outcome surveys for this study were taken from the National Institute of Health’s Patient Reported Outcome Measurement Information System (PROMIS) system. To assess physical and mental health, the PROMIS Global Items Survey with physical and mental subscores, Anxiety, and Depression scores were used. Pain outcomes were assessed using PROMIS Pain Intensity and Pain Interference surveys. Patient-reported lower extremity function was assessed using the PROMIS Mobility Survey. Patient-reported quality of life for sexual function was assessed using the PROMIS Sex Interest and Orgasm survey, whereas incontinence was measured using the International Continence Society Voiding and Incontinence scores and the Modified Obstruction and Defecation Score. Surveys were collected prospectively during clinic visits in the postoperative period. Patients were grouped by the level of osteotomy as determined by review of postoperative MRI or CT and half levels were grouped with the more cephalad level. This resulted in the inclusion of total sacrectomy (N = 6), S1 (N = 8), S2 (N = 10), S3 (N = 5), and S4 (N = 4). One-way analysis of variance tests on means or ranks were used to conduct statistical analysis between levels.ResultsPatients with more caudal resections had higher physical health (95% confidence interval [CI] total sacrectomy 36–42 versus S4 50–64, p < 0.001), less intense pain (95% CI total sacrectomy 47–60 versus S4 28–37, p < 0.001), less interference resulting from pain (95% CI total sacrectomy 58–69 versus S4 36–51, p = 0.004), higher mobility (95% CI total sacrectomy 24–46 versus S4 59–59, p = 0.002), and were more functionally able to achieve orgasm (95% CI S1 1–1 versus S4 2.2–5.3, p = 0.043). No difference was found for PROMIS Global Item Mental Health Subscore, Sex Interest, Sex Satisfaction, modified obstruction and defecation score, and International Continence Society Voiding and Incontinence although this could be the result of an inadequate sample size.ConclusionsOur analysis on patient-reported quality of life based on the level of bony resection in patients who underwent resection for primary sacral tumor indicates that patients with higher resections have more pain and loss of physical function in comparison to patients with lower resections. Additionally, use of the PROMIS outcomes allows for comparisons to normative data.Level of EvidenceLevel III, therapeutic study.

Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery

BackgroundSurgery with high-dose radiation and high-dose radiation alone for sacral chordomas have shown promising local control rates. However, we have noted frequent sacral insufficiency fractures and perceived this rate to be higher than previously reported.Questions/purposesWe wished (1) to characterize the incidence of sacral insufficiency fractures in patients with chordomas of the sacrum who received high-dose radiation, and (2) to determine whether patients treated with surgery plus high-dose radiation or high-dose radiation alone are more likely to experience a sacral fracture, and to compare time to fracture in these groups.MethodsSixty-two patients who received high-dose radiation for sacral chordomas with (n = 44) or without surgical resection (n = 18) between 1992 and 2013 were included in this retrospective study. At our institution, sacral chordomas generally are treated by preoperative radiotherapy, followed by en bloc resection, and postoperative radiotherapy. Radiation alone, with an intent to cure, is offered to patients who otherwise are not good surgical candidates or patients who elect radiotherapy based on tumor location and the anticipated morbidity after surgery (such as sexual, bowel, or bladder dysfunction). MRI and CT scans were evaluated for evidence of sacral insufficiency fractures. Complete followup was available at a minimum of 2 years (or until fracture or death) for all 18 patients who underwent radiation alone, whereas 14% (six of 44 patients) in the surgery plus radiation group (9% [three of 33] after high sacrectomy and 27% [three of 11] after low sacrectomy) were lost to followup before 2 years.ResultsSacral insufficiency fractures occurred in 29 of the 62 patients (47%). A total of 25 of 33 patients (76%) with high sacrectomy had fractures develop compared with zero of 11 (0%) after low sacrectomy, and four of the 18 patients (22%) who had high-dose radiation alone (p < 0.001). The fracture rate was greater in the high sacrectomy group than in the low sacrectomy group (p < 0.001) and the radiation only group (p < 0.001). There was no difference with the numbers evaluated in fracture probability between patients in the low-sacrectomy group and those treated with radiation alone (p = 0.112). The fracture-free survival probability was 0.99 for the low sacrectomy group at all times as there were no insufficiency fractures in this group; the 1-year fracture-free survival probability was 0.53 (95% CI, 0.35–0.69) after high sacrectomy, 0.83 (95% CI, 0.57–0.94) after radiation alone; the 2-year fracture-free survival probability was 0.36 (95% CI, 0.19–0.52) after high sacrectomy and 0.77 (95% CI, 0.50–0.91) after radiation alone; and the 5-year fracture-free survival probability was 0.14 (95% CI, 0.04–0.30) after high sacrectomy and 0.77 (95% CI, 0.50–0.91) after radiation alone.ConclusionsAcknowledging the limitations of potential differences in baseline and followup among treatment groups in our study, we found that almost ½ of our patients experienced an insufficiency fracture. We found that the fracture rate was greater in the surgery group compared with the radiation alone group and that high sacrectomy accounted for all fractures in the surgery group. These findings can be used to inform patients and also support the need for further research to elucidate the influence of high-dose radiation on bone quality.Level of EvidenceLevel III, therapeutic study.

Prior abdominal surgery is associated with an increased risk of postoperative complications after anterior lumbar interbody fusion.

Study Design. Retrospective medical record review. Objective. The purpose of this study was to determine whether a history of abdominal/pelvic surgery confers an increased risk of retroperitoneal anterior approach–related complications when undergoing anterior lumbar interbody fusion. Summary of Background Data. As anterior lumbar interbody fusion gains popularity, both anterior retroperitoneal approach have become increasingly used. Methods. The records of 263 patients, who underwent infraumbilical retroperitoneal approach to the anterior aspect of the lower lumbar spine for a degenerative spine condition between 2007 and 2011 were retrospectively reviewed. Patients demographics, risk factors, preoperative diagnosis, surgical history, level of the anterior fusion, and perioperative complications were collected. Anterior retroperitoneal approach to the spine was carried out by a single general surgeon. Results. Ninety-seven patients (37%) developed at least 1 complication. Forty-nine percent of patients with a history of abdominal surgery developed a postoperative complication compared with 28% of patients without such history (RR = 1.747, P⩽ 0.001). After controlling for other factors such as age, sex, body mass index, diagnostic groups, and preoperative comorbidities (hypertension, diabetes, and smoking status), these differences remained statistically significant. When each type of complication was considered separately, there was a statistically significant difference in the incidence of general complications (RR = 2.384, P = 0.007), instrumentation-related complications (RR = 2.954, P = 0.010), and complications related to the anterior approach (RR = 1.797, P = 0.021). Conclusion. Anterior lumbar interbody fusion via a midline incision and a retroperitoneal approach was associated with 37% overall rate of complication. Patients with a history of abdominal or pelvic surgery are at a higher risk of developing general, instrumentation, and anterior approach–related complications. Level of Evidence: 4

Evaluating the Extent of Clinical Variability Among Treatment Options for Patients With Adult Spinal Deformity.

Study Design: This is a surgical strategy survey. Objective: The purpose of this study was to evaluate the variability in in surgical strategy planning of adult spinal deformity (ASD) based on patients’ clinical and radiographic data. Background: Literature guiding the management of ASD consists primarily of studies with low levels of evidence. Recent studies have demonstrated good agreement among surgeons about the factors influencing surgical decision but poor agreement about the need for surgery. Therefore there is a relative lack of consensus and guidelines in the clinical practice and treatment of ASD. Methods: A total of 28 adult deformity surgeons were asked to fulfill an online survey of 10 spinal deformity cases. Case presentation included a clinical vignette with photographs, Oswestry Disability Index and Visual Analog Scale scores and imaging with radiographic measurements. For each case, the surgeons were asked whether surgical management would be beneficial and if so, their surgical plan (approach, staging, need for fusion, osteotomy or decompression and the techniques used). Intraobserver and interobserver reliability were studied using average Cohen and Feiss Kappa statistics, respectively. Descriptive statistics were calculated to evaluate the frequency of each of the alternatives in surgical planning. Results: Average intrarater and interrater agreement for surgical strategy were evaluated to be substantial (&kgr;=0.62) and fair (&kgr;=0.24), respectively. Detailed interrater statistics demonstrates that there was only slight agreement on the need for surgery (&kgr;=0.15), the approach (&kgr;=0.15), and the need for fusion (&kgr;=0.16) while moderate agreement was reached for the need for decompression (&kgr;=0.42) and osteotomy (&kgr;=0.29). Conclusions: Among surgeons, agreement about the need for surgery and the surgical strategy for ASD is limited. Findings from this survey highlight the need for comprehensive classifications for ASD, higher-level studies including randomized trials to set guidelines and lessen the variability in clinical practices, which would then hopefully lead to improved outcomes.

A 33-year-old Man With Low Back Pain

A 33-year-old man was evaluated in the clinic for a 9-month history of low back pain. The pain was dull and low grade, worse with activity, occasionally waking him at night. He had no history of antecedent trauma. He had no radiation of pain, focal neurologic symptoms, balance difficulties, or difficulties with fine motor tasks. He had tried aspirin with variable relief, and acupuncture and chiropractic care with no significant improvement. He had no medical conditions, never had spine surgery, and never smoked. He exercised daily doing weight lifting and martial arts, with which his back pain interfered. On physical examination, the patient was generally healthy and appeared well. He had midline tenderness to palpation in his midlumbar spine. The patient had normal strength and ROM, and sensation was intact to light touch throughout. He had normal deep tendon reflexes and no long tract signs. He had normal gait and station. AP and lateral plain films (Fig. 1) of the lumbar spine were obtained initially, followed by CT (Fig. 2) and MRI (Fig. 3); the latter tests were ordered owing to the findings we observed on the plain radiographs. Based on the history, physical examination, and imaging studies, what is the differential diagnosis?