Michael Ford

Quality of life in surgical treatment of metastatic spine disease

Study Design. Overall quality of life after surgical management of metastatic disease of the spine was prospectively assessed using a validated global health status quality-of-life instrument—the Edmonton Symptom Assessment Scale. Objectives. To prospectively evaluate the efficacy of surgery in patients with metastatic spinal disease with respect to quality of life. Summary of Background Data. Management of spinal metastases is palliative and is aimed at improving quality of life at an acceptable risk. Although previous studies have evaluated physical outcomes, improvements in pain, and neurologic function after surgery, a multidimensional assessment of quality of life is more relevant in the palliative patient. Methods. Twenty-five consecutive patients undergoing surgery for spinal metastases were prospectively evaluated. Pre- and postoperative assessments were performed using the Edmonton Symptom Assessment Scale. The surgical procedure consisted of decompression and instrumented stabilization. Results. After surgery, the largest improvement was noted in the domain of pain (P < 0.00001). There were also significant improvements noted in the domains of tiredness (P = 0.004), nausea (P = 0.01), anxiety (P = 0.006), drowsiness (P = 0.044), appetite (P = 0.02), and well-being (P = 0.004). Conclusions. The current study demonstrates that in the appropriate patient, surgical management brings about a positive effect on the overall quality of life in patients with spinal metastases. The greatest benefit occurred in the reduction of a patient’s level of pain.

A 2011 Updated Systematic Review and Clinical Practice Guideline for the Management of Malignant Extradural Spinal Cord Compression

PURPOSE To update the 2005 Cancer Care Ontario practice guidelines for the diagnosis and treatment of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MESCC). METHODS A review and analysis of data published from January 2004 to May 2011. The systematic literature review included published randomized control trials (RCTs), systematic reviews, meta-analyses, and prospective/retrospective studies. RESULTS An RCT of radiation therapy (RT) with or without decompressive surgery showed improvements in pain, ambulatory ability, urinary continence, duration of continence, functional status, and overall survival. Two RCTs of RT (30 Gy in eight fractions vs. 16 Gy in two fractions; 16 Gy in two fractions vs. 8 Gy in one fraction) in patients with a poor prognosis showed no difference in ambulation, duration of ambulation, bladder function, pain response, in-field failure, and overall survival. Retrospective multicenter studies reported that protracted RT schedules in nonsurgical patients with a good prognosis improved local control but had no effect on functional or survival outcomes. CONCLUSIONS If not medically contraindicated, steroids are recommended for any patient with neurologic deficits suspected or confirmed to have MESCC. Surgery should be considered for patients with a good prognosis who are medically and surgically operable. RT should be given to nonsurgical patients. For those with a poor prognosis, a single fraction of 8 Gy should be given; for those with a good prognosis, 30 Gy in 10 fractions could be considered. Patients should be followed up clinically and/or radiographically to determine whether a local relapse develops. Salvage therapies should be introduced before significant neurologic deficits occur.

Chevron Osteotomy for the Treatment of Hallux Valgus

Seventy-six chevron osteotomies with follow-up periods ranging from six months to eight years were reviewed. The majority of patients had pain over the bunion prior to operation, and 27 also presented with second metatarsalgia. After surgery there was a marked decrease of pain in the first metatarsophalangeal joint, and in 18 feet the second metatarsalgia was either eliminated or markedly decreased. Most patients were pleased with the appearance of the feet after surgery, but almost one-third of the women complained of difficulty in wearing high heels. The surgical technique is straightforward, but careful attention to detail is necessary to obtain a consistent and satisfactory result.

Relationship between Preoperative Patient Characteristics and Expectations in Candidates for Total Knee Arthroplasty.

PURPOSE The purpose of this study was to determine the relationship between patient expectations for improvement following primary total knee arthroplasty (TKA) and patient preoperative characteristics. METHODS This was a cross-sectional analysis of preoperative expectations. Expectations for improvement were evaluated in six distinct domains. The baseline factors used as independent variables were age, gender, presence of comorbidity, sub-domains of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; pain, stiffness, physical limitation related to lower extremity), and SF-36 physical and mental health component scores. Stepwise logistic regression analysis was applied to examine the relationships between dependent and independent variables. RESULTS The study cohort consisted of 236 candidates for TKA (154 women and 82 men, mean age 67, SD = 9.98). Expectations were high on average. Presence of comorbidity was associated with expectations of pain relief. Preoperative mental health was related to expectations for a return to activities of daily living; age, gender, physical health, and mental health were related to expectations for improved leisure, recreational, and sports activities. Preoperative physical health was related to expectations for potential return to full recovery. No baseline factors were associated with expectations for improved range of motion or for providing care to and interacting with others. CONCLUSION Expectations related to recovery from surgery appeared to have distinct dimensions and were associated with patient baseline characteristics.

The Role of Plain Radiographs in Management of Bone Metastases

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare false-positive results. We present a case with a false-positive result in a patient with lung cancer.

Correlation of Computed Tomography Imaging Features With Pain Response in Patients With Spine Metastases After Radiation Therapy

PURPOSE To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

“The ABCs of AD”: A prospective evaluation of the efficacy of an educational intervention to increase knowledge of autonomic dysreflexia management among emergency health care professionals

Context/Objective: Despite the availability of consensus-based resources, first responders and emergency room (ER) health care professionals (HCPs) have limited knowledge regarding autonomic dysreflexia (AD) recognition and treatment. The purpose of this study was to assess the efficacy of “The ABCs of AD” educational seminar for improving HCPs’ short- and long-term knowledge of AD recognition, diagnosis, and management. Design: Multi-center prospective pre, post, and follow-up questionnaire study. Setting: Level I trauma centers with emergency departments in British Columbia, Manitoba, and Ontario. Methods: ER professionals completed measures immediately before and after (n = 108), as well as 3-months following (n = 23), attendance at “The ABCs of AD” seminar. Outcome Measures: AD knowledge test; seminar feedback. Results: Following the seminar, participants had higher ratings of their AD knowledge and had significantly higher AD knowledge test scores (M ± SD pre = 11.85 ± 3.88, M ± SD post = 18.95 ± 2.39, out of 22; P < 0.001, d = 2.21). Most participants believed the seminar changed their AD knowledge, and rated the seminar information as having the potential to influence and change their practice. AD knowledge test scores significantly decreased between post-seminar and 3-month follow-up (M ± SD 3mo = 17.04 ± 3.28; P = 0.004, d = –0.70); however, 3-month scores remained significantly higher than baseline. Conclusion: “The ABCs of AD” seminar improves HCPs’ perceived and actual AD knowledge in the short-term. To enhance knowledge retention in both the short- and long-term, the inclusion of additional active learning strategies and follow-up activities are recommended. The seminar is being translated into an online training module to enhance the dissemination of the AD clinical practice guidelines among first responders, ER staff, and SCI practitioners.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.

A Biomechanical Assessment of Kyphoplasty as a Stand-Alone Treatment in a Human Cadaveric Burst Fracture Model.

Study Design. In vitro biomechanics study. Objective. To determine whether kyphoplasty is an adequate stand-alone treatment for restoring biomechanical stability in the spine after experiencing high-energy vertebral burst fractures. Summary of Background Data. Kyphoplasty in the treatment of high-energy vertebral burst fractures has been shown by previous studies to significantly improve stiffness when used in conjunction with pedicle screw instrumentation. However, it is not known whether kyphoplasty as a stand-alone treatment may be an acceptable method for restoring biomechanical stability of a spinal motion segment post–burst fracture while allowing flexibility of the motion segment through the intervertebral discs. Methods. Young cadaveric spines (15–50 yr old; 3 males and 1 female; bone mineral density 0.27–0.31 gHA/cm3) were divided into motion segments consisting of 3 intact vertebrae separated by 2 intervertebral discs (T11–L1 and L2–L4). Mechanical testing in axial, flexion/extension, lateral bending, and torsion was performed on each specimen in an intact state, after an experimentally simulated burst fracture and postkyphoplasty. Computed tomography was used to confirm the burst fractures and quantify cement placement. Results. Between the intact and burst-fractured states significant decreases in stiffness were seen in all loading modes (63%–69%). Burst fracture increased the average angulation of the vertebral endplates 147% and decreased vertebral body height by an average of 40%. Postkyphoplasty, only small recoveries in stiffness were seen in axial, flexion/extension, and lateral bending (4%–12%), with no improvement in torsional stiffness. Large angular deformations (85%) and height loss (31%) remained postkyphoplasty as compared with the intact state. Conclusion. Lack of overall improvement in biomechanical stiffness indicates failure of kyphoplasty to sufficiently restore stability as a stand-alone treatment after high-energy burst fracture. The lack of stability can be explained by an inability to biomechanically repair the compromised intervertebral discs. Level of Evidence: 3

Efficacy of postoperative radiation treatment for bone metastases in the extremities

BACKGROUND AND PURPOSE Impending or pathological fractures due to bone metastases may require surgical fixation. Postoperative radiation is often recommended to reduce local progression and prevent prosthesis displacement, hence reducing the need for second surgery. The objectives of this study were to investigate the need for second surgery, and to report on rates of re-irradiation, tumor progression and prosthesis displacement following postoperative radiation. MATERIALS AND METHODS Data were collected from 65 patients who received postoperative radiation to 74 sites in the extremities in a palliative radiation clinic between January 2009 and January 2017. Descriptive statistical analyses were performed. RESULTS Only 2 patients required a second surgery (2.7%) at 9 and 10months after postoperative radiation. Increase in pain requiring re-irradiation was reported in 7 patients (9.5%), at a median time of 9.3months after the delivery of radiation. Of the 47 patients who had radiological imaging available post-radiation, local progression of bone metastases was seen in 8 patients (17.0%) and displacement of the prosthesis in 1 patient (2.1%). CONCLUSION Rates of prosthesis displacement and progression of bone metastases at site of surgery were low after postoperative radiation. There were few incidences of second surgery and re-irradiation observed in the cohort. These findings provide support for the benefit of postoperative radiation.