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Background: Skeletal-related events (SREs), including the pathological fracture, surgical treatment or radiation of bone lesions, malignant spinal cord compression, hypercalcemia, are important considerations when managing metastatic bone tumors; however, owing to their rarity, the incidence of SREs in patients with Ewing sarcoma remains unknown., Methods: We retrospectively reviewed the clinical data from 146 patients with Ewing sarcoma treated at a single institution from 2005 to 2019. The median age at diagnosis was 22.7 years. Fifty patients (34.2%) had metastatic disease at diagnosis. The primary outcome was the SRE-free rate among patients with Ewing sarcoma. Moreover, we identified the risk factors for SREs using univariate or multivariate analyses., Results: During the observational period (median, 2.6 years), SREs occurred in 23 patients. Radiation to the bone, malignant spinal cord compression, and hypercalcemia were documented as the initial SREs in 12 patients (52.2%), 10 patients (43.5%), and one patient (4.3%), respectively. The SRE-free rate was 94.2 ± 2.0, 87.3 ± 3.0, and 79.6 ± 3.8% at 1, 2, and 3 years after the initial visit, respectively. Multivariate analysis revealed bone metastasis at diagnosis (hazard ratio [HR] = 4.41, p = 0.007), bone marrow invasion (HR = 34.08, p < 0.001), and local progression or recurrence after definitive treatment (HR = 3.98, p = 0.012) as independent risk factors for SREs., Conclusions: SREs are non-rare events that can occur during the treatment course for Ewing sarcoma, with an especially high incidence of malignant spinal cord compression. Patients with metastatic disease at diagnosis, especially in the bone or bone marrow, or with local progression or recurrence after definitive treatment, should be carefully monitored for the occurrence of SREs. The most effective methods to monitor the occurrence of SREs and new preventative therapies for SREs should be investigated in the future., (© 2024 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Degenerative cervical myelopathy (DCM) is a poorly recognised form of spinal cord injury which arises when degenerative changes in the cervical spine injure the spinal cord. Timely surgical intervention is critical to preventing disability. Despite this, DCM is frequently undiagnosed, and may be misconstrued as normal ageing. For a disease associated with age, we hypothesised that the elderly may represent an underdiagnosed population. This study aimed to evaluate this hypothesis by comparing age-stratified estimates of DCM prevalence based on spinal cord compression (SCC) data with hospital-diagnosed prevalence in the UK., Methods: We queried the UK Hospital Episode Statistics database for admissions with a primary diagnosis of DCM. Age-stratified incidence rates were calculated and extrapolated to prevalence by adjusting population-level life expectancy to the standardised mortality ratio of DCM. We compared these figures to estimates of DCM prevalence based on the published conversion rate of asymptomatic SCC to DCM., Results: The mean prevalence of DCM across all age groups was 0.19% (0.17, 0.21), with a peak prevalence of 0.42% at age 50-54 years. This contrasts with estimates from SCC data which suggest a mean prevalence of 2.22% (0.436, 2.68) and a peak prevalence of 4.16% at age > 79 years., Conclusions: To our knowledge, this is the first study to estimate the age-stratified prevalence of DCM and estimate underdiagnosis. There is a substantial difference between estimates of DCM prevalence derived from SCC data and UK hospital activity data. This is greatest amongst elderly populations, indicating a potential health inequality., (© 2022. The Author(s).)

Purpose: The aim of this study was to determine the incidence and factors associated with the development of metastatic spinal cord compression (MSCC) after cervical cancer (CC)., Methods: This retrospective cohort of 3551 women with CC who underwent treatment at the Brazilian National Cancer Institute were included in the study. Clinical and sociodemographic variables were obtained from the Hospital Cancer Registry and from hospital records. A descriptive study of the population was carried out, using means and standard deviations or frequencies and percentages. The Kaplan-Meier curve was used to identify annual incidence rates. Associations between the independent variables and the outcome (MSCC) were evaluated by a univariate analysis, applying crude and adjusted odds ratios (aOR) assuming 95% confidence intervals., Results: The MSCC incidence was of 1.5% (n = 51), associated to advanced staging (aOR = 2.65, 95% CI: 1.45-4.85, p = 0.001) and initial treatment with concomitant chemotherapy and radiotherapy (aOR = 4.40, 95% CI: 1.74-11.13, p = 0.002)., Conclusions: Our findings revealed the incidence and factors associated with MSCC, indicating a subset of patients who may be potential targets for the prevention and early treatment of this condition, indicating unprecedented and relevant data for the Brazilian epidemiological scenario due to the high CC incidence rates., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Recently, the prevalence of elderly patients suffering from cervical spinal cord injury (CSCI) without bone injury has been increasing in various countries. Pre-existing factors causing spinal cord compression, such as ossification of the posterior longitudinal ligament (OPLL), can increase the risk of CSCI without bone injury. However, no study has compared the prevalence of pre-existing factors between CSCI with and without bone injury. This study aimed to compare the prevalence of pre-existing factors between CSCI with and without bone injury., Methods: In 168 consecutive patients with CSCI, pre-existing factors including OPLL, posterior spur of the vertebral body, developmental stenosis, disc bulge and calcification of yellow ligament (CYL) were evaluated on imaging studies. The prevalence of each type of pre-existing factors was compared between patients with and without bone injury., Results: The prevalence of pre-existing factors in patients without bone injury (86%) was significantly higher than in those with bone injury (20%) (P < 0.001; odds ratio, 23.9). The most common pre-existing factor was OPLL followed by developmental stenosis, posterior spur, disc bulge and CYL in both groups. OPLL, development stenosis and posterior spur were significantly more common in patients without bone injury compared to those with bone injury (P < 0.01)., Conclusions: Prevalence of pre-existing factors, such as OPLL, development stenosis and posterior spur was significantly higher in patients without bone injury than in those with bone injury. Thus, these pre-existing factors might be a potential risk of CSCI without bone injury., Competing Interests: Declaration of competing interest The submitted manuscript involves no conflicts of interest., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Introduction: prostate cancer represents the 3 rd primary neoplasia responsible for metastatic spinal cord compression (MSCC). MSCC is an extreme oncological emergency, because it involves both functional and vital prognosis. The present study aimed to establish a pattern of MSCC in prostate cancer patients in Douala and Yaoundé general hospitals (Cameroon)., Methods: this was a descriptive and retrospective study in the Radiotherapy and Medical Oncology services at both Douala and Yaoundé General Hospitals. The explored variables were general characteristics of the study population, clinical and paraclinical features, management and outcomes. Furthermore 5-year survival was analyzed by the Kaplan-Meier method. Logistic regression by determining the odd ratios and their 95% confidence was done using "Statistical Package for Social Sciences" (SPSS 23) software. The difference was considered significant at p < 0.05., Results: our series consisted of 151 patients out of which the mean age was 66.88 (SD: 8.71) years (95% CI: 44-88). Pain was the most common clinical symptom (53.33%; n= 80) and fracture-settlement accounted for majority (60%; n= 90.61) of the pain. Thoracic spine damage was encountered by 47.02% (n= 71). Patients received a total doses of irradiation between 20 and 30 gray (Gy). The main toxicity due to radiotherapy were asthenia (45.70%; n= 69.11). The overall survival at 5 years was 90.11%. Factors associated with fracture-settlement were smoking (aOR 10.04, 95% CI: 2.09-48.12; p = 0.004) and the localization of MSCC occurred (aOR 0.21, 95% CI: 0.05-0.77; p = 0.02)., Conclusion: in summary the average age for developing the condition is 66.88 years and factors associated with fracture-settlement were smoking and the localization of MSCC. Back pain was the most common clinical sign and fracture-settlement was the first type of injury on medical magnetic resonance imaging. Therefore, we recommend that emphasis should be placed on increasing awareness of the population on the importance of early diagnosis., Competing Interests: The authors declare no competing interest., (Copyright: Etienne Okobalemba Atenguena et al.)

Background: Although the relationship between amyotrophic lateral sclerosis (ALS) and cervical spondylotic myelopathy (CSM) is important, data relating to CSM complications in ALS remain lacking., Purpose: We aimed to investigate and validate the spinal cord conditions of ALS patients., Materials and Methods: We recruited all patients diagnosed with ALS, Parkinson's disease (PD), or chronic inflammatory demyelinating polyneuropathy (CIDP) who were admitted to our department from April 1, 2017, to March 31, 2020. We analyzed the cervical or thoracolumbar magnetic resonance imaging (MRI) scans of these 128 patients. Data relating to spondylosis, cord compression, spinal canal diameter, spinal cord diameter, and the closest distance between the cervical spinal canal and cord were validated using MRI., Results: Of the 128 patients, 52 had ALS, 48 had PD, and 28 had CIDP. The proportions of both cervical spondylosis and cervical cord compression were highest in the ALS group compared with the other patient groups (p < 0.05). The proportion of cervical spondylosis in ALS patients reached 38.3%, and that of cervical cord compression reached 53.2%. The closest distance between the cervical spinal canal and cord was also significantly smaller in ALS patients compared with CIDP patients (p < 0.05). In contrast to the cervical cord findings, there were no significant differences in the thoracolumbar cord between ALS patients and the other patient groups., Conclusions: Of the three disease groups, the proportion of CSM was highest in ALS patients. Furthermore, cervical cord conditions were significantly more crowded in the ALS patients than in the other patient groups., (© 2021. Fondazione Società Italiana di Neurologia.)

Introduction: Bone metastases occur frequently in castration-resistant prostate cancer (CRPC) and may lead to skeletal-related events (SREs), including symptomatic skeletal events (SSEs). Bone-modifying agents (BMAs) delay SREs and SSEs. However, the real-world use of BMAs is debated given the absence of demonstrated survival advantage and potential adverse events (AEs). Our retrospective study examined BMA use and SSE rates in Australian patients with CRPC., Methods: Patients with CRPC and bone metastases were identified from the electronic CRPC Australian Database. Patient characteristics, treatment patterns and AEs were analysed. Descriptive statistics reported baseline characteristics, SSE rates and BMA use. Comparisons between groups used t-tests and Chi-square analyses. Overall survival was calculated by the Kaplan-Meier method., Results: A total of 532 eligible patients were identified with a median age of 73 years (range: 44-97 years). BMAs were prescribed in 232 men (46%), 183 of whom received denosumab. Patients receiving first-line docetaxel for CRPC were more likely to commence BMAs than those receiving abiraterone or enzalutamide (51% vs 31% vs 38%; p = 0.004). SSEs occurred in 148 men (28%), most commonly symptomatic lesions requiring intervention (75%). At the time of initial SSEs, only 28% were receiving BMAs. Patients treated at sites with lower BMA use (

Background: Degenerative compressive myelopathy (DCM) is caused by cervical cord compression. The relationship between the magnitude and clinical findings of cervical cord compression has been described in the literature, but the details remain unclear. This study aimed to clarify the relationship between the magnitude and clinical symptoms of cervical cord compression in community-dwelling residents., Methods: The present study included 532 subjects. The subjective symptoms and the objective findings of one board-certified spine surgeon were assessed. The subjective symptoms were upper extremity pain and numbness, clumsy hand, fall in the past 1 year, and subjective gait disturbance. The objective findings were: Hoffmann, Trömner, and Wartenberg signs; Babinski's and Chaddock's signs; hyperreflexia of the patellar tendon and Achilles tendon reflexes; ankle clonus; Romberg and modified Romberg tests; grip and release test; finger escape sign; and grip strength. Using midsagittal T2-weighted magnetic resonance imaging, the anterior-posterior (AP) diameters (mm) of the spinal cord at the C2 midvertebral body level (DC2) and at each intervertebral disc level from C2/3 to C7/T1 (DC2/3-C7/T1) were measured. The spinal cord compression ratio (R) for each intervertebral disc level was defined and calculated as DC2/3-C7/T1 divided by DC2. The lowest R (LR) along C2/3 to C7/T1 of each individual was divided into 3 grades by the tertile method. The relationship between LR and clinical symptoms was investigated by trend analysis., Results: The prevalence of subjective gait disturbance increased significantly with the severity of spinal cord compression (p = 0.002812), whereas the other clinical symptoms were not significantly related with the severity of spinal cord compression., Conclusions: The magnitude of cervical cord compression had no relationship with any of the neurologic findings. However, subjective gait disturbance might be a better indicator of the possibility of early stage cervical cord compression., Competing Interests: NO authors have competing interests.

Study Design: We retrospectively analyzed Spinal Instability Neoplastic Score (SINS) in 110 patients with prostate cancer operated for metastatic spinal cord compression (MSCC)., Objective: We aimed to investigate the association between SINS and clinical outcomes after surgery for MSCC in patients with prostate cancer., Summary of Background Data: The SINS is a useful tool for assessing tumor-related spinal instability, but its prognostic value regarding survival and neurological outcome is still controversial., Methods: We analyzed 110 consecutive patients with prostate cancer who underwent surgery for MSCC. The patients were categorized according to their SINS. Patients with castration-resistant prostate cancer (CRPC, n = 84) and those with hormone-naïve disease (n = 26) were analyzed separately., Results: In total, 106 of 110 patients met the SINS criteria for potential instability or instability (scores 7-18). The median SINS was 10 (range 6-15) for patients with CRPC and 9 (7-16) for hormone-naïve patients. In the CRPC group, the SINS was classified as stable (score 0-6) in 4 patients, as potentially unstable (score 7-12) in 70 patients, and as unstable (score 13-18) in 10 patients. In the hormone-naïve group, 22 patients met the SINS criteria for potential instability and 4 patients for instability. There was no statistically significant difference in the overall risk for death between the SINS potentially unstable and unstable categories (adjusted hazard ratio 1.3, P = 0.4), or in the risk of loss of ambulation 1 month after surgery (adjusted odds ratio 1.4, P = 0.6)., Conclusion: The SINS is helpful in assessing spinal instability when selecting patients for surgery, but it does not predict survival or neurological outcomes. Patients with a potential spinal instability benefit equally from surgery for MSCC as do patients with spinal instability.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose: Cerebellar tonsillar herniation arises frequently in syndromic craniosynostosis and causes central and obstructive apneas in other diseases through spinal cord compression. The purposes of this study were the following: 1) to determine the prevalence of cervical spinal cord compression in syndromic craniosynostosis, and 2) to evaluate its connection with sleep-disordered breathing., Materials and Methods: This was a cross-sectional study including patients with syndromic craniosynostosis who underwent MR imaging and polysomnography. Measures encompassed the compression ratio at the level of the odontoid process and foramen magnum and the cervicomedullary angle. MR imaging studies of controls were included. Linear mixed models were developed to compare patients with syndromic craniosynostosis with controls and to evaluate the association between obstructive and central sleep apneas and MR imaging parameters., Results: One hundred twenty-two MR imaging scans and polysomnographies in 89 patients were paired; 131 MR imaging scans in controls were included. The mean age at polysomnography was 5.7 years (range, 0.02-18.9 years). The compression ratio at the level of the odontoid process was comparable with that in controls; the compression ratio at the level of the foramen magnum was significantly higher in patients with Crouzon syndrome (+27.1, P  < .001). The cervicomedullary angle was significantly smaller in Apert, Crouzon, and Saethre-Chotzen syndromes (-4.4°, P  = .01; -10.2°, P  < .001; -5.2°, P  = .049). The compression ratios at the level of the odontoid process and the foramen magnum, the cervicomedullary angle, and age were not associated with obstructive apneas ( P  > .05). Only age was associated with central apneas ( P  = .02)., Conclusions: The prevalence of cervical spinal cord compression in syndromic craniosynostosis is low and is not correlated to sleep disturbances. However, considering the high prevalence of obstructive sleep apnea in syndromic craniosynostosis and the low prevalence of compression and central sleep apnea in our study, we would, nevertheless, recommend a polysomnography in case of compression on MR imaging studies., (© 2021 by American Journal of Neuroradiology.)

Objective: The population prevalence of non-small cell lung cancer (NSCLC) continues to increase; however, data are limited regarding the incidence rate of skeletal related events (SREs) (i.e., surgery to the spinal column, radiation to the spinal column, radiofrequency ablation, kyphoplasty/vertebroplasty, spinal cord compression, or pathological vertebral body fractures) and their impact on overall mortality. In this study, the authors sought to estimate the incidence rates of SREs in NSCLC patients and to quantify their impact on overall mortality., Methods: This was a single-institution retrospective study of patients diagnosed with NSCLC between 2002 and 2014. The incidence rates for bone metastasis and subsequent SREs (per 1000 person-years) by time since lung cancer diagnosis were calculated and analyses were stratified separately for each histological type. Incidence rates for mortality at 1, 2, and 3 years from diagnosis stratified by the presence of SREs were also calculated. Kaplan-Meier survival curves were constructed to describe crude survival ratios in patients with spine metastasis and SREs and those with spine metastasis but without SREs. These curves were used to estimate the 1- and 2-year survival rates for each cohort., Results: We identified 320 patients with incident NSCLC (median follow-up 9.5 months). The mean ± SD age was 60.65 ± 11.26 years; 94.48% of patients were smokers and 60.12% had a family history of cancer. The majority of first-time SREs were pathological vertebral body compression fractures (77.00%), followed by radiation (35%), surgery (14%), and spinal cord compression (13.04%). Mortality rates were highest in NSCLC patients with spine metastasis who had at least 1 SRE. Stratifying by histological subtype, the incidence rate of mortality in patients with SRE was highest in the large cell cohort, 7.42 per 1000 person-years (95% CI 3.09-17.84 per 1000 person-years); followed by the squamous cell cohort, 2.49 per 1000 person-years (95% CI 1.87-3.32 per 1000 person-years); and lowest in the adenocarcinoma cohort, 1.68 per 1000 person-years (95% CI 1.46-1.94 per 1000 person-years). Surgery for decompression of neural structures and stabilization of the spinal column was required in 6% of patients., Conclusions: SREs in NSCLC patients with bone metastasis are associated with an increased incidence rate of mortality.

Background: Skeletal-related events (SREs) are significant contributors to the morbidity and mortality in patients with bone metastasis from breast cancer. Thus, bone-modifying agents (BMAs) are recommended in this population. However, the baseline risk factors of SREs in patients with bone metastasis from breast cancer receiving BMAs are not well understood., Methods: We analyzed the patient-level data from a controlled arm of a clinical trial comparing denosumab with zoledronate in patients with bone metastases from breast cancer (ClinicalTrial.gov ID: NCT00321464) available at Project Data Sphere, a broad-access research platform that collects and curates patient-level data from completed, phase III cancer trials. The primary endpoint was the first SRE after the inclusion to the trial. The time to the first on study SRE was analyzed using Cox proportional hazards model based on patients' baseline characteristics including age, race, ECOG performance status (PS), histology and immunohistochemistry of breast cancer, and urine and serum laboratory data., Results: Among 756 patients in the zoledronate arm of the trial, we excluded 64 patients with a documented history of osteopenia or osteoporosis. The median age of the patients was 56 years old, the median follow-up was 553 days, and 249 patients (36%) had SREs. The univariate analysis showed that black or African American heritage, ECOG PS > 0, human epidermal growth factor receptor 2 (HER2) positivity, high urine N-telopeptide cross-links / creatinine ratio (NTx/Cre), and elevated serum alkaline phosphatase (ALP) are significant baseline risk factors for SREs. Patients with the characteristics of ECOG PS > 0, HER2 positivity, and elevated ALP also showed a significantly higher hazard ratio of SREs in multivariate analysis., Conclusions: We determined risk factors for SREs in patients with bone metastasis from breast cancer.

Introduction: Cervical spinal sarcoidosis can mimic compressive cervical myelopathy leading to potentially harmful surgical procedures before the diagnosis can be made., Methods: Retrospective description of 3 patients and review of the literature., Results: Twenty-seven patients (16 men/11 women), median age 58 years [range 29-74] were described. Neurosurgical procedures consisted of laminectomy (n=10), laminoplasty (n=15) and anterior discectomy (n=2). Immediately after surgery, 17 patients (63%) worsened or remained disabled. Among the 10 patients who improved, 9 worsened secondarily. The analysis of preoperative MRI showed T2 hypersignal lesions and contrast enhancement in all patients. Neurological symptoms were inaugural in 25/27 patients, and systemic involvement of the sarcoidosis was found after surgery in 15/27 patients. After surgery, all patients received corticosteroids, along with immunosuppressive therapy in 8 cases/27. After a follow-up of 24 [16-72] months; 13 patients were stabilized or worsened, 7 were partially improved. Three died of other cause. Only 5 recovered without sequelae., Conclusion: In patients with compressive cervical myelopathy, leptomeningeal contrast enhancement, a T2-weighted hypersignal exceeding the compression level on MRI, and the presence of extraneurological symptoms should point to inflammatory disease. These rare manifestations may be the first symptoms of sarcoidosis and should be recognized to avoid harmful surgical procedures and to provide appropriate medical treatment., (Copyright © 2019 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Background: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED., Methods: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality., Results: We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess)., Conclusion: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Common signs and symptoms of cervical myelopathy (CM) predominantly manifest in the upper extremities and include hand numbness, hand clumsiness, and distal upper extremity weakness. CM manifesting without symptoms in the upper extremities is rare. This study aimed to better understand the incidence and character of such cases., Methods: A retrospective review of surgeries for CM from disc herniation, spondylosis, or ossification of posterior longitudinal ligament over a 12-year period was performed to identify patients presenting without symptoms in the upper extremities., Results: Of 982 surgically treated patients with CM, 12 (1.2%) had no upper extremity symptoms. All had difficulty ambulating, and 7 of 12 (58%) patients had objective lower extremity weakness. Ten (83%) patients had a history of lumbar degenerative disease. On sensory examination, 4 (33%) patients had a discernible midthoracic pin level, 3 (25%) had loss of sensation from the upper leg and genital area down, and 2 (17%) had only genital/upper thigh area sensory loss. All patients demonstrated neurologic improvement after decompressive surgery., Conclusions: Patients with CM may rarely present without symptoms in the upper extremities, presenting with numbness perceived from the upper trunk, waist area, or perineum and legs in addition to leg weakness and gait difficulty. All patients had cervical cord compression at either C5-6 or C6-7 level, accounting for 1% of all patients undergoing cervical surgery. Awareness of this atypical pattern of presentation may aid in clinical assessment of a subset of patients with cervical cord compression., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Non-osteoporotic skeletal-related events (SREs) are clinically important markers of disease progression in prostate cancer. We developed and validated an approach to identify SREs in men with prostate cancer using routinely-collected data., Methods: Patients diagnosed with prostate cancer between January 2010 and December 2013 were identified in the National Prostate Cancer Audit, based on English cancer registry data. A coding framework was developed based on diagnostic and procedure codes in linked national administrative hospital and routinely-collected radiotherapy data to identify SREs occurring before December 2015. Two coding definitions of SREs were assessed based on whether the SRE codes were paired with a bone metastasis code ('specific definition') or used in isolation ('sensitive definition'). We explored the validity of both definitions by comparing the cumulative incidence of SREs from time of diagnosis according to prostate cancer stage at diagnosis with death as a competing risk., Results: We identified 40,063, 25,234 and 13,968 patients diagnosed with localised, locally advanced and metastatic disease, respectively. Using the specific definition, we found that the 5-year cumulative incidence of SREs was 1.0 % in patients with localised disease, 6.0 % in patients with locally advanced disease, and 42.3 % in patients with metastatic disease. Using the sensitive definition, the corresponding cumulative incidence figures were 9.0 %, 14.9 %, and 44.4 %, respectively., Conclusion: The comparison of the cumulative incidence of SREs identified in routinely collected hospital data, based on a specific coding definition in patients diagnosed with different prostate cancer stage, supports their validity as a clinically important marker of cancer progression., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective cross-sectional cohort., Objective: To investigate the prevalence and predictive factors of concurrent cervical spinal cord compression (CSCC) in patients with adult spinal deformity (ASD)., Summary of Background Data: In patients with ASD undergoing major thoracolumbar realignment surgery, concurrent CSCC potentially increases the risk of progression of myelopathy or cervical cord injury due to various perioperative factors including poor intraoperative neck positioning and hypotension. However, the prevalence of CSCC in ASD patients has not been previously studied., Methods: This study included ASD patients who were indicated for major thoracolumbar corrective surgery (>5 levels). The presence of CSCC was determined using the modified Cord Compression Index (Grades 0-3) based on the cervical magnetic resonance imaging (MRI). Significant CSCC was defined as Grade>2, and the distribution of compression level as well as the number of Grade>2 segments were investigated in each patient. A multivariate regression analysis was performed to identify the predictors of CSCC with variables being the patients' characteristics including radiographic sagittal alignment parameters., Results: Of 121 patients with ASD, 41 patients (33.8%) demonstrated significant CSCC on MRI. Intramedullary T2 hyper-intensity (myelomalacia) was present in eight patients (6.6%). Thirty-five of 41 patients were asymptomatic or with myelopathy that is difficult to detect. Significant CSCC was most commonly observed at C4/5 level. Four patients (3.3%) underwent cervical decompression and fusion prior to thoracolumbar reconstruction. Multivariate regression analysis revealed old age, increased body mass index (BMI), and PI-LL mismatch independently predicted the CSCC grade., Conclusion: The prevalence of concurrent significant cervical cord compression in patients with ASD is relatively high at 33.8%. Preoperative evaluation of cervical MRI and examinations for signs/symptoms of myelopathy are essential for patients with (1) older age, (2) increased BMI, and (3) high PI-LL mismatch to avoid progressive myelopathy or cord injury during ASD surgery., Level of Evidence: 4.

Study Design: General population utility valuation study., Objective: This study obtained utility valuations from a Canadian general population perspective for 31 unique metastatic epidural spinal cord compression (MESCC) health states and determined the relative importance of MESCC-related consequences on quality-of-life., Summary of Background Data: Few prospective studies on the treatment of MESCC have collected quality-adjusted-life-year weights (termed "utilities"). Utilities are an important summative measure which distills health outcomes to a single number that can assist healthcare providers, patients, and policy makers in decision making., Methods: We recruited a sample of 1138 adult Canadians using a market research company. Quota sampling was used to ensure that the participants were representative of the Canadian population in terms of age, sex, and province of residence. Using the validated MESCC module for the "Self-administered Online Assessment of Preferences" (SOAP) tool, participants were asked to rate six of the 31 MESCC health states, each of which presented varying severities of five MESCC-related dysfunctions (dependent; non-ambulatory; incontinent; pain; other symptoms)., Results: Participants equally valued all MESCC-related dysfunctions which followed a pattern of diminishing marginal disutility (each additional consequence resulted in a smaller incremental decrease in utility than the previous). These results demonstrate that the general population values physical function equal to other facets of quality-of-life., Conclusion: We provide a comprehensive set of ex ante utility estimates for MESCC health states that can be used to help inform decision making. This is the first study reporting direct utility valuation for a spinal disorder. Our methodology offers a feasible solution for obtaining quality-of-life data without collecting generic health status questionnaire responses from patients., Level of Evidence: 4.

Malignant spinal cord compression (MSCC) is a potentially devastating consequence of cancer. Early recognition of the signs and symptoms of MSCC can allow diagnosis prior to the development of irreversible complications. Information provision to patients and doctors regarding the risk of MSCC and a streamlined pathway for further investigation are both key to improving the outcome for patients developing this condition. Described in this paper is the development of such a pathway at Aberdeen Royal Infirmary., Competing Interests: DL reports an Educational Grant from Novartis

Background: Early diagnosis and management of diseases takes a center stage in the control and prevention of chronic debilitating disorders. It also plays a prominent role in ensuring that patients are better equipped on how to deal with the disease burden. One reliable means of achieving this objective is to retrospectively study the frequency of common diseases., Materials and Methods: This was a retrospective study conducted between January 2010 and December 2014. Relevant data were extracted from patients' case folders. Adjustment to correct for potential biases such as multiple admissions and secondary diagnosis using a covariate on admission data was made to correct for systematic error. Information obtained was analyzed for frequency and distribution., Results: The mean age of the patients was 44.9 years (standard deviation ± 16.7), with an age range of 15-99 years. The most common neurological disorder was stroke which accounted for 21.3%, followed by spinal cord compression syndromes (20.8%), epilepsy (17.3%), parkinsonian syndromes (8.9%), headaches (7.1%), and bacterial meningitis (5.2%). The highest number of cases of neurological disorder occurred within the age group of 45-54 years., Conclusion: The outcome of this study revealed that stroke and spinal cord compression syndromes were the most common neurological disorders in our center. It also showed that individuals within their productive age (50-54 years) were more affected. Given the present state of constrained resources, coordinated efforts at the institutional, state, and federal government levels are essential to encourage prioritization, funding, and implementation of effective health-care delivery system., Competing Interests: None

Background: Degenerative changes of the cervical spinal column are the most common cause of spinal cord lesions in the elderly. Conventional clinical, electrophysiological and radiological diagnostics of spinal cord compression are often inconsistent., Materials and Methods: The feasibility and diagnostic potential of a novel T1 mapping method at 0.5 mm resolution and 4 s acquisition time was evaluated in 14 patients with degenerative cervical spinal canal stenosis (SCS) and 6 healthy controls. T1 mapping was performed in axial sections of the stenosis as well as above and below. All subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological and clinical examinations., Results: Patients revealed significantly decreased T1 relaxation times of the compressed spinal cord within the SCS (912 ± 53 ms, mean ± standard deviation) in comparison to unaffected segments above (1027 ± 39 ms, p < .001) and below (1056 ± 93 ms, p < .001). There was no difference in mean T1 in unaffected segments in patients (p = .712) or between segments in controls (p = .443). Moreover, T1 values were significantly lower in grade II (881 ± 46 ms, p = .005) than in grade I SCS (954 ± 29 ms). Patients with central conduction deficit tended to have lower T1 values within the SCS than patients without (909 ± 50 ms vs 968 ± 7 ms, p = .069)., Conclusion: Rapid high-resolution T1 mapping is a robust MRI method for quantifying spinal cord compression in patients with cervical SCS. It promises additional diagnostic insights and warrants more extended patient studies., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Cervical laminectomy is an effective treatment for multilevel cervical compressive myelopathy. Symptomatic spinal cord compression (SSCC) by paraspinal musculature (PSM) following cervical laminectomy is rarely reported. The aim of this study was to evaluate the frequency and pathogenesis of this complication after cervical laminectomy., Methods: Between 2007 and 2016, the medical records of 1309 cervical laminectomy patients were reviewed. From these 1309 records, seven patients (five men and two women; average age, 64.12 years; range 48-78 years) with SSCC by PSM following cervical laminectomy were identified. The incidence and possible risk factors of this rare condition were evaluated., Results: The frequency of SSCC by PSM following cervical laminectomy was 0.53%. Presenting symptoms included paralyses and paresthesias, depending on the level and severity of cervical spinal cord compression. The initial onset of neurologic deterioration varied from 12 h to 21 days after operation. Most patients recovered well after surgical management with an average Barthel index of 74.3 at 6 months after surgery. In comparison with 63 controls, this rare complication was associated with preoperative cervical kyphosis, prior antiplatelet therapy, and posterior decompression with prone position., Conclusions: SSCC by PSM is a rare but devastating complication following cervical laminectomy, especially in those patients with preoperative kyphosis, prior antiplatelet treatment, and decompression with prone position. MRI is an ideal tool to identify this complication. Rapid cervical cord decompression and avoidance of recurrent compressive events can achieve a good clinical outcome. These slides can be retrieved under Electronic Supplementary Material.

Objective: To evaluate the outcome of patients with epidural spinal cord compression from different solid tumors treated with a combined approach, surgery plus radiotherapy (RT), with a follow-up longer than 10 years., Methods: Ninety-seven patients treated between 2002 and 2009 were included. Surgical treatment was performed in patients with good performance status, limited metastatic disease, life expectancy longer than 3 months, and progressive neurologic deficit and/or intractable pain. RT was performed delivering a median total dose of 30 Gy in 10 fractions. Clinical outcome was evaluated using the modified visual analog scale for pain, the Frankel scale for neurologic deficit, and magnetic resonance imaging before treatment, after treatment, and every 3 months thereafter., Results: Palliative decompression was performed in 27% of patients, tumor curettage (debulking) was performed in 51%, and total vertebrectomy was performed in 22%, followed by RT in 78% of cases. Pain remission was obtained in 98% of patients, and recovery of neurologic function was obtained in 51%. The median follow-up time was 135 months (range, 96-209 months). The 5- and 10-year local control rates were 82.8% and 82.8%, respectively. The median and 5- and 10-year progression-free survival rates were 12 months, 16.9%, and 11.3%, respectively; the median and 5- and 10-year overall survival rates were 18 months, 21.3%, and 12%, respectively. On univariate and multivariate analysis, factors recorded as conditioning survival were the performance status and the presence of other metastases at the time of vertebral treatment (P < 0.01)., Conclusions: Our update confirmed that surgery plus RT is a safe and feasible treatment with limited morbidity. In selected patients with favorable prognostic factors, the combined treatment may significantly impact on survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Spine and nonspine skeletal metastases occur in more than 80% of patients with prostate cancer., Objective: To examine the characteristics of the patient population undergoing surgery for the treatment of prostate cancer metastatic to the spine., Methods: A retrospective chart review was performed on all patients treated at our institution from June 1993 to August 2014 for surgical management of metastatic spine disease from prostate cancer., Results: During the study period, 139 patients with 157 surgical lesions underwent surgery for metastatic spine disease. Decompression for high-grade epidural spinal cord compression was required for 126 patients with 143 lesions. Preoperatively, 69% had a motor deficit and 21% were nonambulatory, with 32% due to motor weakness. At surgery, 87% of patients had hormone-refractory prostate cancer (HRPC) and 61% failed prior radiation. Median overall survival for HRPC patients was 6.6 mo (95% confidence interval [CI]: 5.6-8.6) while the median overall survival for hormone-sensitive patients was 16.3 mo (95% CI: 4.0-26.6)., Conclusion: The majority of patients undergoing surgery for prostate cancer metastases to the spine were refractory to hormone therapy, indicating that patients with hormone-sensitive prostate cancer are unlikely to develop symptomatic spinal cord compression or spinal instability. A significant number of HRPC patients presented with neurological deficits attributable to spinal cord compression. Vigilant monitoring for the development of signs and symptoms of epidural spinal cord compression and spinal instability in hormone-refractory patients is recommended. Surgical decision making may be affected by the much shorter postoperative survival for HRPC patients as compared to patients with hormone-sensitive cancer.

Objective: Real-world data regarding patient factors associated with the occurrence of spinal cord compression (SCC) or pathological fracture (PF), or need for bone surgery (BS), or use of radiation therapy (RAD) (i.e. skeletal complications and radiation therapy; SCRT) are limited for women with metastatic breast cancer (BCa). Given the substantial clinical and economic burden of these events in advanced BCa, we conducted the present study to understand the prevalence and identify the risk factors associated with these events among elderly women presenting with de novo metastatic BCa., Methods: Using linked Surveillance, Epidemiology, and End Results and Medicare data, we identified women with incident metastatic BCa diagnosed during 2005-2009. Associations between patient demographics and select clinically relevant factors, and SCRT were examined using the Cox proportional hazards model, accounting for death as a competing risk., Results: Of 3,731 Medicare beneficiaries with incident metastatic BCa, 1,808 (48.5%) experienced at least one SCRT event during a median follow-up of 13.2 months; a majority (69%) experienced a subsequent SCRT event. The proportions of women who had RAD, PF, BS, and SCC were: 32%, 28%, 8%, and 4%. Older women (80+ years), or those with more comorbid conditions (CCI≥2) had a statistically significant lower risk of SCRT (HR 0.78 [CI: 0.67-0.92, p<0.01]; HR 0.77 [CI: 0.67-0.89, p<0.01], respectively), primarily due to lower frequency of radiotherapy (p<0.01). Compared to Caucasians, African Americans had lower risk of SCRT (HR 0.70 [CI: 0.60-0.82, p<0.01]), as well as all SCRT subtypes defining this group except for SCC, which was the same for both race groups., Conclusion: This study highlights that certain patient characteristics and clinical factors are associated with the risk of spinal cord compression or pathologic fractures, or need for bone surgery or radiation among women with metastatic BCa. In future studies, it will also be important to consider the clinical and economic burden based on these components of skeletal complications and radiation therapy use in order to guide and improve the management of women with advanced BCa.

Purpose: The Tokuhashi revised score from 2005 (TR2005) is the most recommended prognostic scoring system in patients with metastatic spinal cord compression (MSCC). However, recent studies have questioned its prognostic ability and the need for a new revision has been proposed. We aimed to assess whether a revision of the TR2005 can improve the prognostic ability of the scoring system., Methods: In 2011 and 2012, a total of 1143 consecutive patients admitted with MSCC were prospectively included in a 2011 and a 2012 cohort. For the patients admitted in 2011 (n = 544), the components of the TR2005 including primary cancer diagnosis were analyzed regarding the prognostic ability. Based on these findings, a revision of the TR2005 score was defined as the Tokuhashi revised score 2017 (TR2017). The prognostic abilities of the TR2005 and the TR2017 were compared by Kaplan Meyer (KM) curves, and receiver-operating characteristics' (ROC) analysis was compared in a cohort of patients admitted in 2012 (n = 599)., Results: KM curves and ROC analysis showed that the TR2017 had better prognostic ability compared to the TR2005. The ROC areas were as follows: <6-months survival, TR2017 = 0.71 and TR2005 = 0.65, and p = 0.003; for ≥6-month survival, TR2017 = 0.71 and TR2005 = 0.65, and p = 0.003; for ≥12-month survival TR2017 = 0.72 and TR2005 = 0.67, and p = 0.0015., Conclusions: The TR2017 can improve the prognostic ability of the TR2005 in patients with MSCC. This could affect the preoperative evaluation of patients suffering from MSCC.

Degenerative cervical spondylosis (DCM) is an umbrella term used to describe myelopathy caused by various degenerative changes in the cervical spine. This article outlines the spectrum of DCM and reviews the epidemiology of each factor composing DCM. The uniform term of DCM is expected to elucidate the epidemiology of myelopathy caused by degenerative changes of the cervical spine.", (Copyright © 2017 Elsevier Inc. All rights reserved.)

Because of improving treatments and survival, 40% to 58% of patients with bone metastases from nonsmall cell lung cancer (NSCLC) will suffer from at least one skeletal-related event (SRE), affecting their quality of life, but the natural history of SRE is poorly understood. The study aimed to examine the factors involved in SRE-free survival (SRS) and overall survival (OS) of patients with NSCLC and bone metastases.This was a retrospective study of 211 patients with bone metastasis from NSCLC and treated at the Tumor Hospital Affiliated to Harbin Medical University between January 2007 and January 2012. OS and SRS were evaluated by the Kaplan-Meier method. The factors associated with SRS and OS were examined using multivariate Cox analyses.The 1 year OS was 55.9% and the median OS was 30 months (range, 1-98 months). Multivariate analyses showed that clinical staging at initial diagnosis (P < .001) and SRE (P = .033) were independently associated with OS, and clinical staging at initial diagnosis (P = .009), bone pain (P = .008), primary tumor radiotherapy (P < .001), and chemotherapy (P = .031) were independently associated with SRS. Stage I, II, and III patients under biphosphonate therapy fared better than those without biphosphonate treatment, but there was no difference for stage IV patients.The identification of factors associated with OS and SRS of patients with NSCLC and bone metastases should provide new clues for a better management of these patients., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Skeletal-related events (SREs) are common complications of bone metastatic castration-resistant prostate cancer (mCRPC). To the authors' knowledge, there are limited data regarding which factors predict SREs. The authors identified risk factors for SREs in men with bone mCRPC using characteristics commonly available in the medical record., Methods: Data from 454 patients with nonmetastatic CRPC were identified from 2 Veteran Affairs Medical Centers from 2000 through 2013. Among these men, 233 (51%) developed bone metastases during follow-up and represented the study cohort. First occurrence of an SRE was abstracted from the medical records. A stepwise multivariable Cox model was used to select the strongest predictors of time to SRE., Results: The median age of the patients at the time of diagnosis of bone mCRPC was 75 years (interquartile range, 68-81 years), and there were 153 nonblack patients (66%). During follow-up (median, 7.8 months [interquartile range, 2.9-18.3 months]), 88 patients (38%) had an SRE. On univariable analysis, more recent year of metastasis (hazard ratio [HR], 0.91), prostate-specific antigen doubling time of ≥9 months versus <9 months (HR, 0.50), and bone pain (HR, 3.34) were all found to be associated with SRE risk. On multivariable analysis, year of metastasis (HR, 0.93), biopsy Gleason score of 7 versus ≤6 (HR, 1.74), radiotherapy as the primary localized treatment versus none (HR, 2.33), and bone pain (HR, 3.64) were associated with SRE risk. The area under the curve for a multivariable model based upon these risk factors was 0.744., Conclusions: The authors identified several significant predictors of SREs among men with mCRPC. In particular, men with bone pain are at high risk of an SRE. If confirmed, future trials should focus on prolonging life and reducing SRE risk in patients with mCRPC with bone pain. Cancer 2017;123:1528-1535. © 2017 American Cancer Society., (© 2016 American Cancer Society.)

Background: Congenital fusion of cervical vertebrae, including Klippel-Feil syndrome (KFS), is a suspected risk factor for development of degenerative cervical myelopathy (DCM). We aimed to establish prevalence and degenerative patterns of congenital cervical fusion (CCF) among a global cohort of patients with DCM., Methods: Data from 3 prospective DCM studies were merged, including clinical data for 813 patients and imaging for 592 patients. CCF was diagnosed by presence of fused cervical vertebrae without signs of degenerative fusion. A wasp-waist sign was used to define a KFS subgroup. Characteristics of patients with CCF and the KFS subgroup were compared with the remainder of patients with DCM., Results: Twenty-three patients with CCF (14 KFS) were identified, indicating a prevalence of 3.9% (2.4% KFS). Patients with CCF were older (P = 0.02), had more operated levels (P = 0.01), had higher rates of ossified posterior longitudinal ligament (P = 0.02), and demonstrated worse degenerative changes at C3-4, including spinal cord compression (P = 0.002) and T 2 weighted image T2WI signal hyperintensity (P = 0.04). Levels adjacent to fusions showed a trend toward increased spinal cord compression (P = 0.09), with fusions at C3-4 or above showing cord compression below in 9 of 10 patients, fusions at C5-6 or below having cord compression above in 8 of 8 patients, and fusions at C4-5 showed cord compression above and below in 2 of 2 patients., Conclusions: The prevalence of CCF and KFS is higher in DCM than for the general population, suggesting that these patients are predisposed to DCM development. Patients with CCF also have an altered pattern of degenerative changes, seemingly related to adjacent segment degeneration that preferentially affects midcervical levels., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: We aimed to critically analyze the current evidence regarding the role of dynamic supine magnetic resonance imaging (dsMRI) in the evaluation of cervical spondylotic myelopathy., Methods: Thirteen studies were identified through a comprehensive literature search performed in the PubMed, EMBASE, and ISI databases as fulfilling the inclusion criteria and were reviewed for subject characteristics, radiographic parameters, and salient findings., Results: Studies herein reviewed suggested that dsMRI was able to detect new appearance or increased grade of medullary compression in ≥20% of patients and to demonstrate an average narrowing of the cervical canal by 20% (in comparison with the neutral position). Several additional parameters were investigated, but their clinical significance remained unconfirmed. Two studies examined how surgical decision-making could be affected by the additional findings of dsMRI., Conclusions: dsMRI represents an available modification of conventional static magnetic resonance imaging and is potentially able to demonstrate pathologies that might be previously missed. Evidence suggests that dsMRI can elucidate spinal cord compression with higher sensitivity, resulting in improved diagnostic accuracy of cervical spondylotic myelopathy, which may impact surgical planning for these patients. However, more high-quality studies are required to further establish its indications to avoid overdiagnosis with this powerful imaging technique and to justify its cost-effectiveness., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional population-based observational study., Objective: To estimate the prevalence of nonmyelopathic spondylotic cervical cord compression (NMSCCC) and cervical spondylotic myelopathy (CSM) in a population older than 40 years and to evaluate the magnetic resonance imaging (MRI) characteristics of these conditions., Summary of Background Data: The prevalence of neither NMSCCC nor CSM is known and there exists no commonly accepted quantitative MRI definition of cervical cord compression., Methods: A group of 183 randomly recruited volunteers, 93 women, median age 66 years, range 40-80 years, underwent MRI examination of the cervical spine and spinal cord on a 1.5 T device using conventional sequences from disc levels C2/C3 to C6/C7. The imaging criterion for cervical cord compression was defined as a change in spinal cord contour at the level of an intervertebral disc on axial or sagittal MRI scan., Results: MRI signs of cervical cord compression were found in 108 individuals (59.0%; 95% CI: 51.5%-66.2%); their numbers increased with age from 31.6% in the fifth decade to 66.8% in the eighth. Clinical signs of symptomatic CSM were found in two cases (1.1%), and 75 cases (41.0%) were without compression. An anteroposterior cervical canal diameter at the level of intervertebral disc (CDdisc) of less than 9.9 mm was associated with the highest probability of NMSCCC-odds ratio (OR) = 32.5, followed by a compression ratio of ≤0.5: OR = 11.1., Conclusion: The prevalence of NMSCCC in a population older than 40 years is higher than previously reported and increases with age. CDdisc and compression ratio had the highest capacity to discriminate between subjects with and without asymptomatic compression, and their cut-off values could be used to objectify criteria for cervical cord compression., Level of Evidence: 2.

Context: Bone metastases (BM) can lead to devastating skeletal-related events (SREs) in cancer patients. Data regarding medullary thyroid carcinoma (MTC) with BM are lacking., Objective: We evaluated the natural history of BM and SREs in MTC patients identified by a cancer center tumor registry., Setting: The study was conducted at a tertiary cancer center., Patients and Main Outcome Measures: We retrospectively reviewed the charts of MTC patients with BM who received care from 1991 to 2014 to characterize BM and SREs., Results: Of 1008 MTC patients treated, 188 were confirmed to have BM (19%), of whom 89% (168 of 188) had nonosseous distant metastases. Median time from MTC to BM diagnosis was 30.9 months (range 0-533 mo); 25% (45 of 180) had BM identified within 3 months of MTC diagnosis. Median follow-up after detecting BM was 1.6 years (range 0-23.2 y). Most patients (77%) had six or more BM lesions, most often affecting the spine (92%) and pelvis (69%). Many patients (90 of 188, 48%) experienced one or more SREs, most commonly radiotherapy (67 of 90, 74%) followed by pathological fracture (21 of 90, 23%). Only three patients had spinal cord compression. Patients with more than 10 BM lesions were more likely to experience SREs (odds ratio 2.4; P = .007), with no difference in 5-year mortality after MTC diagnosis between patients with (31%) and without SREs (23%) (P = .11)., Conclusions: In this large retrospective series, BM in MTC was multifocal, primarily involving the spine and pelvis, supporting screening these regions for metastases in at-risk patients. SREs were common but spinal cord compression was rare. Antiresorptive therapies in this population should be investigated further with prospective trials.

The purpose of this study was to estimate the risk of developing skeletal-related events (SREs) based on site of metastasis at diagnosis and identify other predictors of developing SREs among metastatic prostate cancer patients. We conducted a retrospective cohort study using linked SEER (Surveillance, Epidemiology, and End Results) and Medicare data and identified men over the age of 65 with incident metastatic prostate cancer diagnosed during 2005-2009. SREs included radiation (RAD), pathological fractures (PF), bone surgery (BS), and spinal cord compression (SCC). The association between site of metastasis at diagnosis and SRE was examined using a Cox proportional hazards model that accounts for death as a competing risk. Among 4404 men (median age: 79 years) with incident metastatic prostate cancer, 44% experienced SREs at a median of 9.6 months post diagnosis. Compared to bone metastasis only, our model showed that patients were significantly less likely to develop SREs if they had LN-only metastasis at diagnosis (Sub-Hazard Ratio [SHR] 0.56; 95% Confidence Interval [CI]: 0.43-0.72) or unknown site of metastasis (SHR: 0.79; CI: 0.64-0.97). Other predictors of reduced SRE risk were age 80+ years (SHR: 0.83; CI: 0.75-0.91), non-Hispanic Black (SHR: 0.77; CI: 0.65-0.90), or being diagnosed in year 2009 (SHR: 0.85; CI: 0.72-0.99). Patients were significantly more likely to develop SREs if they received androgen deprivation therapy (SHR: 1.73; CI: 1.48-2.02) or had Gleason score 8-10 disease (SHR: 0.79; CI: 0.64-0.97). Compared to patients who present with bone metastasis only at diagnosis, patients presenting with other metastatic sites have similar risk of developing SREs, with the exception of those presenting with lymph node only metastasis who have a significantly reduced risk of SREs., (© 2016 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Objective: Identify risk factors predisposing to thoracic spinal stenosis and myelopathy (TS) and address treatment options and outcomes., Methods: A retrospective review of our center's experience with TS over 10 years. Clinical and magnetic resonance imaging (MRI) data, surgical intervention and outcomes using Frankel and Japanese Orthopedic Association (JOA) scales were collected., Results: A total of 44 patients with TS were identified. There were 30 men and 14 women with a mean age±SD of 66±15years. Neurological performance was evaluated using the Frankel scale (A-E or 1-5), and JOA scale for myelopathy (0-11). Frankel scores (1-5) and JOA scores (0-11) on admission were 3.5±0.9 and 6.8±2.6 respectively. At follow-up, Frankel scores had improved to 4.1±0.8 (p=0.041) and JOA scores had improved to 8.3±2.4 (p=0.021). The presence on admission of increased signal from the cord on T2-weighted MRI was associated with lower Frankel and JOA scores (3.3±0.9, and 6.2±2.5 respectively) than in those with absent increased signal (4.0±0.4 and 8.6±2.1, p=0.02 and p=0.008 respectively). There were 4 complications, requiring exploration and debridement for dehiscence in 3 and an epidural hematoma in the fourth that necessitated evacuation, with a good outcome. A fifth patient underwent reoperation at the same level 18 months later for persistent stenosis., Conclusion: Thoracic stenosis with myelopathy should be entertained in patients with myelopathy. Over half of our patients with TS were over the age of 70, and men outnumbered women by a ratio of 2:1. Nearly half the patients with TS had concomitant cervical and/or lumbar degenerative disease warranting surgery also. Increased signal intensity on T2-weighted MRI images correlated with lower Frankel and JOA scores compared to those without. Decompression for thoracic stenosis is associated with neurological improvement., (Copyright © 2016 Elsevier B.V. All rights reserved.)

OBJECTIVE Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field. METHODS A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency. RESULTS The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations). CONCLUSIONS The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.

Purpose: Narrow cervical canal (NCC) has been a suspected risk factor for later development of cervical myelopathy. However, few studies have evaluated the prevalence in asymptomatic subjects. The purpose of this study was to investigate the prevalence of NCC in a large cohort of asymptomatic volunteers., Methods: This study was a cross-sectional study of 1211 asymptomatic volunteers. Approximately 100 men and 100 women representing each decade of life from the 20s to the 70s were included in this study. Cervical canal anteroposterior diameters at C5 midvertebral level on X-rays, and the prevalence of spinal cord compression (SCC) and increased signal intensity (ISI) changes on MRI were evaluated. Receiver operating characteristic analysis was performed to determine the cut-off value of the severity of canal stenosis resulting in SCC., Results: NCC (<14 mm) was observed in 123 (10.2 %) subjects. SCC and ISI were found in 64 (5.3 %) and 28 (2.3 %) subjects, respectively. The prevalence of NCC was significantly higher in females and older subjects, but the occurrence of severe NCC (<12 mm) did not increase with age. The canal size in subjects with SCC or ISI was significantly smaller than in those without SCC (p < 0.0001). The cut-off values of cervical canal stenosis resulting in SCC were 14.8 and 13.9 mm in males and females, respectively., Conclusions: The prevalence of NCC was considerably lower among asymptomatic healthy volunteers; the cervical canal diameter in subjects with SCC or ISI was significantly smaller than in asymptomatic subjects; NCC is a risk factor for SCC.

Study Design: A cross-sectional study., Objective: This study aims to investigate the correlation of the cervical canal and spinal cord size, and evaluate whether the size of the spinal cord relative to the spinal canal is a risk factor for development of cervical spinal cord compression (SCC)., Summary of Background Data: There is little knowledge regarding the relationship between cervical bony canal and spinal cord diameters. Although developmental canal stenosis has been recognized as a risk factor for SCC, the size of the spinal cord relative to the spinal canal has not been similarly discussed., Methods: Cervical canal anteroposterior (AP) diameters on X-rays and AP diameters and cross-sectional areas of dural sacs and spinal cords on magnetic resonance imaging (MRI) were measured in 1211 healthy volunteers. Correlation between cervical canal diameter on X-rays and AP diameter and cross-sectional area of dural sacs and spinal cords on MRI were assessed. The ratio of the AP diameter of the spinal cord/dural sac was compared between subjects with and without SCC., Results: Spinal canal diameters were not highly correlated with spinal cord AP diameters and cross-sectional areas, although spinal canal diameters were significantly correlated with dural sac AP diameters. The individual difference in the ratio of the AP diameter of the spinal cord/dural sac was large (35%-93%), and the ratio was significantly larger in the subjects with SCC. An AP diameter ratio more than 62% at the C2 to C3 disc level is a risk factor for developing SCC., Conclusion: The spinal cord diameter was independent of the spinal canal diameter and the relative size of a spinal cord and spinal canal differed on an individual basis. In addition, the ratio of spinal cord/dural sac in subjects with SCC was significantly larger. Therefore, a relatively large spinal cord could be a risk factor for SCC.

Objective: To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI)., Design: A retrospective cohort design was employed, using data retrieved from administrative databases., Setting: Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011., Participants: Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation., Outcome Measures: Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics., Results: There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%)., Conclusion: Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.

The proportion of the population over age 65 in the United States continues to increase over time, from 12% in 2000 to a projected 20% by 2030. There is an associated rise in the prevalence of degenerative spinal disorders with this aging population. This will lead to an increase in demand for both nonsurgical and surgical treatment for these disabling conditions, which will stress an already overburdened healthcare system. Utilization of spinal procedures and services has grown considerably. Comparing 1999 to 2009, lumbar epidural steroid injections have increased by nearly 900,000 procedures performed per year, while physical therapy evaluations have increased by nearly 1.4 million visits per year. We review the literature regarding the cost-effectiveness of spinal surgery compared to conservative treatment. Decompressive lumbar spinal surgery has been shown to be cost-effective in several studies, while adult spinal deformity surgery has higher total cost per quality-adjusted life year gained in the short term. With an aging population and unsustainable healthcare costs, we may be faced with a shortfall of beneficial spine care as demand for spinal surgery in our elderly population continues to rise., Abbreviation: QALY, quality-adjusted life year.

Background: Skeletal related events (SREs) are common in men with metastatic prostate cancer (mPC). Various methods have been used to identify SREs from claims data. The objective of this study was to provide a framework for measuring SREs from claims and compare SRE prevalence and cumulative incidence estimates based on alternative approaches in men with mPC., Methods: Several claims-based approaches for identifying SREs were developed and applied to data for men aged [greater than or equal to] 66 years newly diagnosed with mPC between 2000 and 2009 in the SEER-Medicare datasets and followed through 2010 or until censoring. Post-diagnosis SREs were identified using claims that indicated spinal cord compression (SCC), pathologic fracture (PF), surgery to bone (BS), or radiation (suggestive of bone palliative radiation, RAD). To measure SRE prevalence, two SRE definitions were created: 'base case' (most commonly used in the literature) and 'alternative' in which different claims were used to identify each type of SRE. To measure cumulative incidence, we used the 'base case' definition and applied three periods in which claims were clustered to episodes: 14-, 21-, and 28-day windows., Results: Among 8997 mPC patients, 46 % experienced an SRE according to the 'base case' definition and 43 % patients experienced an SRE according to the 'alternative' definition. Varying the code definition from 'base case' to 'alternative' resulted in an 8 % increase in the overall SRE prevalence. Using the 21-day window, a total of 12,930 SRE episodes were observed during follow up. Varying the window length from 21 to 28 days resulted in an 8 % decrease in SRE cumulative incidence (RAD: 10 %, PF: 8 %, SCC: 6 %, BS: 0.2 %)., Conclusions: SRE prevalence was affected by the codes used, with PF being most impacted. The overall SRE cumulative incidence was affected by the window length used, with RAD being most affected. These results underscore the importance of the baseline definitions used to study claims data when attempting to understand relevant clinical events such as SREs in the real world setting.

Study Design: Ambispective study., Objective: To determine whether MRI parameters improve the predictive performance of a validated clinical prediction rule used to assess functional outcomes in surgical patients with DCM., Summary of Background Data: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in the elderly worldwide. A clinical prediction rule was developed to discriminate between patients with mild myelopathy postoperatively (mJOA ≥ 16) and those with substantial residual neurological impairment (mJOA < 16). Recently, a separate magnetic resonance imaging (MRI)-based prediction model was created. However, a model exploring the combined predictive value of imaging and clinical variables does not exist., Methods: One hundred and fourteen patients with MRIs were examined from a cohort of 278 patients enrolled in the AOSpine CSM-North America Study. Ninety-nine patients had complete preoperative imaging and postoperative outcome data. MRIs were evaluated for the presence/absence of signal change on T2- and T1-weighted images. Quantitative analysis of the T2 signal change was conducted and maximum canal compromise and cord compression were calculated. The added predictive performance of each MRI parameter to the clinical model was evaluated using receiver operator characteristic curves., Results: The model developed on our subsample yielded an area under the receiver operator curve (AUC) of 0.811 (95% CI: 0.726-0.896). The addition of imaging variables did not significantly improve the predictive performance. Small improvements in prediction were obtained when sagittal extent of T2 hyperintensity (AUC: 0.826, 95% CI: 0.743-0.908, 1.35% increase) or Wang ratio (AUC: 0.823, 95% CI: 0.739-0.907, 1.21%) was added. Anatomic characteristics, such as maximum canal compromise and maximum cord compression, did not improve the discriminative ability of the clinical prediction model., Conclusion: In our sample of surgical patients, with clinical and image-evidence of DCM, MRI parameters do not significantly add to the predictive performance of a previously published clinical prediction rule. It remains plausible that combinations of the strongest clinical and MRI predictors may yield a similar or a superior prediction model., Level of Evidence: 3.

Background Context: Bone metastasis (BM) occurs frequently in patients with lung cancer (LC). The most affected are the bones of the spine, increasing the risk of developing metastatic spinal cord compression (MSCC). Although MSCC is one of the most disabling complications, few studies have reported relevant results related to its frequency and prognosis among patients with LC., Purpose: The purpose of this study was to determine the incidence and associated factors of the development of MSCC after BM with LC and its prognosis., Study Design/setting: This is a cohort study., Patient Sample: A cohort of 112 patients with BM because of LC, whose treatment was performed exclusively at the National Cancer Institute, was analyzed., Outcome Measures: Study outcome measures included incidence of MSCC, factors associated with MSCC, and survival analysis., Methods: A cohort study was performed involving patients with BM because of LC diagnosed between 2007 and 2011. Clinical and sociodemographic data were extracted from the physical and electronic medical records because of initial diagnosis (up until December 2013). The association between the independent variables and the outcomes was performed by using crude and adjusted odds ratios (ORs), assuming 95% confidence intervals (CIs). For the exploratory evaluation between the independent variables and the time until the outcomes, Kaplan-Meier survival analysis was conducted. To identify if the differences between the curves were statistically significant, a log-tank test was calculated. A Cox multiple regression model, using the forward stepwise method, was applied, aiming to estimate the factors associated with time to death in the different exposure groups., Results: Of the 112 patients with BM, 31 (27.7%) developed MSCC. The univariate analysis showed that patients with three or more involved vertebrae revealed a 6.1 times greater risk of developing MSCC, compared with those with up to two metastatic vertebrae involved (OR: 6.1, 95% CI: 2.5-15.1, p<.001). Among the patients who developed MSCC, the median survival time was 4.4 months (95% CI: 1.5-7.3) and 4.7 months (95% CI: 3.5-5.9) in the patients without MSCC, not being a statistically significant difference (p=.19). After the occurrence of the MSCC, the median survival time was 2.8 months (95% CI: 1.4-4.1)., Conclusions: In this study, a high incidence of MSCC was observed in patients with BM. The study suggests that patients with three or more involved vertebrae per metastasis are more likely to develop MSCC. No alteration in the overall survival time was noticed among the patients with or without MSCC., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to examine the relationship between the location of the cervical cord compression and the increased signal intensity within the cervical cord on T2-weighted imaging (T2WI) in patients with cervical myelopathy and myelomalacia., Materials and Methods: We reviewed 1,615 MRI reports from January 2011 to May 2013 from a single institution. Of the 1,615 reports reviewed, 168 patients were diagnosed with increased signal intensity within the cervical spine on T2WI. After applying the exclusion criteria 82 patients were included in the study. The MRIs of these 82 patients were then reviewed and the location of the increased signal intensity on T2WI in relation to the location of the pressure on the spinal cord was recorded., Results: In more than 50 % of the cases the lesions with increased signal intensity on T2WI either were located distal to the pressure on the spinal cord or started at the level of the pressure and extended to an area distal to the pressure. In 26 out of the 92 lesions with increased signal intensity on T2WI, the lesion started proximal to the pressure on the spinal cord and extended distal to it. In only 3 out of the 92 lesions, the lesion with increased signal intensity on T2WI was solely located proximal to the pressure on the spinal cord. In 5 other cases the lesion with increased signal intensity on T2WI started proximal to the level of pressure on the spinal cord and extended into the level of pressure on the spinal cord (p < 0.001; Table 1)., Conclusion: Cervical myelomalacia may appear proximal, distal or at the level of the compressed cord. It rarely appears solely proximal to the pressure area on the cord.

Background: A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer., Methods: We used the SEER-Medicare database to identify patients >65 years with stage IV (n = 14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT., Results: MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery ± RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39-2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14-7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62-0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47-0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25-2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized., Conclusions: We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.

The optimal surgical strategy for anterior or posterior approaches remains controversial for multilevel cervical compressive myelopathy caused by multisegment cervical spondylotic myelopathy (MCSM) or ossification of the posterior longitudinal ligament (OPLL). A systematic review and meta-analysis was conducted evaluating the clinical results of anterior decompression and fusion (ADF) compared with posterior laminoplasty for patients with multilevel cervical compressive myelopathy. PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials and nonrandomized cohort studies conducted from 1990 to May 2013 comparing ADF with posterior laminoplasty for the treatment of multilevel cervical compressive myelopathy due to MCSM or OPLL. The following outcome measures were extracted: Japanese Orthopedic Association (JOA) score, recovery rate, complication rate, reoperation rate, blood loss, and operative time. Subgroup analysis was conducted according to the mean number of surgical segments. Eleven studies were included in the review, all of which were prospective or retrospective cohort studies with relatively low quality indicated by GRADE Working Group assessment. A definitive conclusion could not be reached regarding which surgical approach is more effective for the treatment of multilevel cervical compressive myelopathy. Although ADF was associated with better postoperative neural function than posterior laminoplasty in the treatment of multilevel cervical compressive myelopathy due to MCSM or OPLL, there was no apparent difference in the neural function recovery rate between the 2 approaches. Higher rates of surgery-related complication and reoperation should be taken into consideration when ADF is used for patients with multilevel cervical compressive myelopathy. The surgical trauma associated with corpectomy was significantly higher than that associated with posterior laminoplasty., (Copyright 2014, SLACK Incorporated.)

Study Design: A prospective clinical study., Objective: To investigate the dynamic causative factor in the pathogenesis of myelopathy in patients with cervical ossification of the posterior longitudinal ligament (OPLL) using kinematic computed tomography (CT) myelography., Summary of Background Data: Kinematic CT myelography is useful for dynamically evaluating the cervical spine with high-resolution images, particularly in bony compressive lesions. However, no studies have evaluated the dynamic factors in patients with OPLL using kinematic CT myelography., Methods: From 2008 to 2013, 51 consecutive patients with OPLL who presented with myelopathy were prospectively enrolled in this study. The patients were examined with kinematic (flexion-extension) CT myelography using a multidetector CT scanner. The range of motion at C2-C7 from flexion to extension was measured in the sagittal view. The segmental range of motion, anterior-posterior diameter and cross-sectional area (CSA) of the spinal cord were measured at the level where the spinal cord was most compressed by OPLL., Results: The neurological condition of the patients evaluated by Japanese Orthopaedic Association scores were 10.8 ± 2.4 points. The mean range of motion at C2-C7 and at the most compressed segment were 23.1 ± 11.7 and 7.0 ± 4.4°, respectively. Both the anterior-posterior diameter and the CSA at the most compressed levels were significantly decreased during neck extension compared with flexion. Interestingly, the anterior-posterior diameter and the CSA were decreased during neck flexion in 13.7% (7/51) of the patients. All 7 of these patients had massive OPLL with an occupying rate 60% or more. The dynamic change rate of CSA (flexion/extension) was significantly smaller in patients with an OPLL occupying rate 60% or more compared with patients with an occupying rate less than 60%., Conclusion: Although spinal cord compression was increased during neck extension in most of the patients, greater levels of compression could be placed on the spinal cord during neck flexion when the patients had OPLL with a high occupying rate., Level of Evidence: 4.

Purpose: To document the risk of skeletal complications in patients with bone metastases from breast cancer (BC), lung cancer (LC), or prostate cancer (PC) in routine clinical practice., Methods: We used data from two large US health systems to identify patients aged ≥18 years with primary BC, LC, or PC and newly diagnosed bone metastases between January 1, 1995 and December 31, 2009. Beginning with the date of diagnosis of bone metastasis, we estimated the cumulative incidence of skeletal-related events (SREs) (spinal cord compression, pathologic fracture, radiation to bone, bone surgery), based on review of medical records, accounting for death as a competing risk., Results: We identified a total of 621 BC, 477 LC, and 721 PC patients with newly diagnosed bone metastases. SREs were present at diagnosis of bone metastasis in 22.4, 22.4, and 10.0 % of BC, LC, and PC patients, respectively. Relatively few LC or PC patients received intravenous bisphosphonates (14.8 and 20.2 %, respectively); use was higher in patients with BC, however (55.8 %). In BC, cumulative incidence of SREs during follow-up was 38.7 % at 6 months, 45.4 % at 12 months, and 54.2 % at 24 months; in LC, it was 41.0, 45.4, and 47.7 %; and in PC, it was 21.5, 30.4, and 41.9 %. More than one half of patients with bone metastases had evidence of SREs (BC: 62.6 %; LC: 58.7 %; PC: 51.7 %), either at diagnosis of bone metastases or subsequently., Conclusions: SREs are a frequent complication in patients with solid tumors and bone metastases, and are much more common than previously recognized in women with BC.