Polina Osler

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.

Clinical Outcomes of Inadequate Calorie Delivery and Protein Deficit in Surgical Intensive Care Patients

BACKGROUND Adequate nutritional therapy in critically ill patients is integral to optimal outcome. OBJECTIVE To evaluate the association between cumulative macronutrient deficit and overall morbidity in surgical intensive care unit patients. METHODS Adult patients receiving enteral nutrition for more than 72 hours were included if they had no previous admission to the surgical intensive care unit, had received no enteral feedings before admission, had no intestinal obstruction or ileus, and survived 72 hours or more after admission. Data on demographics, outcomes, and nutritional intake during the unit stay were collected for up to 14 days until oral intake began, discharge, or death. Outcome variables included lengths of stay in the hospital and intensive care unit, days with no mechanical ventilation, complications, and mortality. RESULTS Of 94 participants, 71% were men, mean age was 63 years, and mean score on the Acute Physiology and Chronic Health Evaluation II was 14. Patients with high cumulative calorie deficit (≥ 6000 cal) and high protein deficit (≥ 300 g) had significantly fewer days with no mechanical ventilation (P < .001), longer unit stays (P < .001), longer hospital stays (P = .007), more total complications (P = .007), and more infectious complications (P = .009) than other participants. These associations remained significant in multivariable models after adjustments for age, sex, reason for admission, and propensity score of deficit. In-hospital and 30-day mortality did not differ. CONCLUSIONS Cumulative macronutrient deficits have important clinical outcomes in surgical intensive care patients.

Comparison of Intrawound Vancomycin Utility in Posterior Instrumented Spine Surgeries Between Patients With Tumor and Nontumor Patients.

Study Design. Retrospective cohort study of consecutive patients. Objective. To compare the efficacy of intrawound vancomycin to prevent postoperative surgical site infection (SSI) between patients with spinal tumor and nontumor spine patients. Summary of Background Data. Recent studies have suggested that intrawound vancomycin is a promising method for reducing the SSI rate in spine surgery. However, the patient population in which it is most effective remains unknown. Methods. Medical records of a consecutive series of patients with tumor and nontumor spine patients who underwent open posterior instrumented surgeries at our institution between October 2011 and June 2014 were reviewed. 1 gram of vancomycin powder was evenly sprayed into the surgical site before drain placement. The SSI rates before and after vancomycin use were compared. Changes in SSI rates, which reflected the utility of vancomycin, were compared between patients with tumor and nontumor patients. Results. A total of 334 patients were enrolled including 25 patients with tumor and 129 nontumor patients in the “before” period, and 27 patients with tumor and 153 nontumor patients in the “after” period. Baseline characteristics in both patients with tumor and nontumor patients did not differ between periods. The SSI rate of nontumor patients was significantly reduced with intrawound vancomycin application (7.0% [9/129] vs. 0.7% [1/153], P = 0.011). However, the SSI rate in patients with tumor was not reduced (8.0% [2/25] vs. 14.8% [4/27], P = 0.442). 3 of the 4 patients with tumor who developed SSI after vancomycin use had previous radiotherapy, whereas only 1 SSI occurred in 14 patients with tumor without radiotherapy in the same period. Conclusion. Intrawound vancomycin may be beneficial for nontumor spine patients who undergo open posterior instrumented surgeries, but may not for those with spinal tumors. The poor physical health status, major surgical trauma, and tumor-related adjuvant treatments of patients with spinal tumor may contribute to this disparity. Level of Evidence: 3

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

Cemented Total Hip Arthroplasty With Retrograde Ischioacetabular Steinmann Pin Reconstruction for Periacetabular Metastatic Carcinoma

BACKGROUND Surgical management of advanced periacetabular lesions is challenging because of extensive bone loss, particularly for Modified American Academy of Orthopaedic Surgeons Classification defects type IV (pelvic discontinuity with posterior column involvement). Multiple methods for rebuilding the acetabulum have been described; all involve passing Steinmann pins in a retrograde or an antegrade fashion from the anterior iliac wing or iliac crest around the acetabulum in an attempt to recreate the normal bony anatomy. However, these techniques fail to engage the ischium in its entirety. The ischial contribution to the posterior column is a critical element in a stable acetabular construct. METHODS After curettage of the acetabular lesion, Steinmann pins are passed through the ischial tuberosity and posterior column into the sciatic buttress in a retrograde manner. The number of pins depends on the size of the defect and involvement of the posterior column. PATIENTS AND METHODS Medical records of 11 patients with a Modified American Academy of Orthopaedic Surgeons Classification defect type IV treated with retrograde ischioacetabular Steinmann pin reconstruction at our institution between 2007 and 2012 were reviewed. European Quality of Life-5 dimensions and Lower Extremity Functional Scale questionnaires were used to assess patient functional outcomes. RESULTS The 6 patients (4 females and 2 males; age range, 56-81 years) surviving 12 months postoperatively reported improved mobility and good quality-of-life scores. CONCLUSION We described a new method for posterior acetabular column reconstruction that uses the ischial tuberosity and body as additional points of stabilization during the reconstruction of the posterior column.

Utility of postoperative radiographs after anterior lumbar interbody fusion with or without posterior instrumentation.

Study Design. Retrospective clinical and radiographical review. Objective. To evaluate the utility of plain radiographical surveillance after anterior lumbar interbody fusion and determine to what extent radiographical findings affect postoperative decision making. Summary of Background Data. Postoperative radiographical surveillance is a ubiquitous practice among spine surgeons, which lacks evidence and has received growing attention in an environment of increasing health care cost and receding resources. Lumbar interbody fusions are being performed with increasing frequency from numerous approaches; nonetheless, there are no evidence-based guidelines for postoperative radiographical evaluation of patients after these procedures. Methods. One hundred forty-six consecutive patients who underwent anterior lumbar interbody fusion with or without short segment posterior fusion from 2008 to 2011 were reviewed. Exclusion criteria were less than 6 months of follow-up, prior surgery, hybrid constructs with disc arthroplasty, and concurrent posterior fusion of greater than 3 levels. Three hundred fifty-nine radiographical series and 330 clinic notes of the included 67 patients were reviewed. Radiographs were evaluated for abnormalities and clinic notes reviewed for any changes in clinical management by multiple reviewers. Interobserver reliability, sensitivity, specificity, and positive and negative predictive values were calculated. Results. There was no single instance of a change in treatment course based on radiographical findings alone in any of the 330 clinic visits of the 67 included patients during an average 15.8-month postoperative follow-up period. Thirty-four of the 67 patients (51%) had some change in their management on the basis of their clinical symptoms and/or examination. Interobserver agreement for change in management was 0.96 (&kgr; = 0.918). Sensitivity (6%), specificity (97%), positive predictive value (67%), and negative predictive value (50%) were calculated. Conclusion. Routine postoperative radiographical surveillance has minimal value for asymptomatic patients after anterior lumbar interbody fusion with or without posterior fusion. Obtaining a limited number of postoperative films of these patients in the absence of clinical symptoms or risk factors could significantly reduce health care costs and unnecessary radiation exposure. Level of Evidence: 4

Aspirin Versus Heparin for Management of Cerebellar Stroke After Vertebral Artery Dissection Following C1-C2 Fracture-Dislocation

Vertebral artery dissection (VAD) in the setting of a C1-C2 fracture-dislocation occurs in up to 20% of cervical spine trauma cases1-4. In young persons, it is one of the leading causes of ischemic stroke in the cerebellum5,6. It is important to recognize the signs of cerebellar and brain-stem infarctions in patients with cervical trauma and to initiate appropriate treatment. There is considerable controversy regarding the optimal course of treatment following a VAD7. We report a case of a patient with a unilateral VAD following a C1-C2 fracture-dislocation after falling from a horse. The patient was managed with heparin anticoagulation and subsequently developed a large retroperitoneal hematoma, a known complication of anticoagulation. We also review the current literature and guidelines regarding the clinical management of these patients. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A sixty-seven-year-old woman was admitted to the emergency department after falling off a horse from a height of approximately six feet and landing on her back. She reported immediate and persistent neck pain and an inability to turn the neck, but demonstrated no neurological deficits. Computed tomography (CT) of the neck showed a rotatory subluxation of C1 on C2 and a left C1-C2 facet dislocation with an associated avulsion fracture (Figs. 1-A through 1-D). The distal segments of the left vertebral artery beyond the fracture site were not visualized by magnetic resonance (MR) angiography, which is consistent with vessel compression (Figs. 2-A through 2-F). Fig. 1 Figs. 1-A through 1-F CT of the cervical spine showing the C1-C2 vertebral fracture-dislocation. Figs. 1-A and 1-B Neck CT prior to reduction. The severity of the rotatory deformity can be seen on the three-dimensional CT reconstructions. The overlapping axial CT …

Spontaneous Dural Tear Presenting as an Acute-onset Headache After a Minor Fall: A Case Report

Dural tears are occasionally encountered intraoperatively due to damage by surgical instruments1-3 or bone fragments being resected. Traumatic dural tears have been reported in a few cases of severe high-energy trauma4. Nontraumatic or spontaneous dural tears are exceedingly rare because of the amount of force that is needed to rupture the dura. We report a unique case of a patient with a spontaneous large symptomatic dural tear at the C7-T1 level of the spine that developed after a minor fall. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A previously healthy thirty-six-year-old woman was transferred to our hospital with a six-day history of severe bifrontal headaches. The symptoms started after she slipped and fell on outstretched hands against a wall. Two days later, the patient developed persistent bifrontal headaches, accompanied by nausea and midline upper back pain whenever she was upright. The only other trauma history had occurred nineteen years previously when she fell twenty feet onto her back during an Air Force training exercise, reportedly “injuring her T1 vertebra,” according to an Air Force physician. No advanced imaging was carried out at that time. After the earlier fall, the patient had experienced a sensation of “heat” from the neck to the lower back as well as pain in these areas. She subsequently had improved without intervention and had remained asymptomatic. Upon presentation to us, the physical examination showed that the patient was afebrile without neurological deficits. On a pain scale of 0 to 10, she reported that the headache ranked a 10 when she was upright, and became a 0 when she was supine. Computed tomography (CT) and magnetic resonance imaging (MRI) of the spine showed no abnormalities (Fig. 1 …

A Left Nonrecurrent Inferior Laryngeal Nerve in a Patient with Vascular and Atlantoaxial Abnormalities: A Case Report

Case: We present a case of a fifty‐eight‐year‐old woman with chronic occipital headaches and neck pain who underwent C2‐C3 anterior and posterior fusion for cervical instability. Perioperative discovery of multiple cervical anomalies, including a left nonrecurrent inferior laryngeal nerve, greatly complicated the approach. Conclusion: A left nonrecurrent inferior laryngeal nerve is a rare anatomical anomaly that may co‐occur with other cervical abnormalities. It is an important anatomical variant to consider during an anterior approach to the cervical spine, especially when preoperative images of the cervical region show vascular and cervical spine anatomical anomalies.