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Purpose: The objective of this study was to evaluate the reporting of racial, ethnic, and socioeconomic data in clinical trials exploring the management of metastatic spine disease (MSD)., Methods: We undertook a cross-sectional analysis of North American completed and published clinical trials registered on ClinicalTrials.gov exploring the management of patients with MSD. Data on patient demographics, trial characteristics, reporting of race and ethnicity, distribution of racial and ethnic groups, and reporting of socioeconomic measures was extracted from ClinicalTrials.gov and related publications identified through PubMed and Google Scholar searches. An exploratory data analysis was performed, followed by Pearson's Chi-square and binary logistic regression analyses to explore associations of covariates with racioethnic reporting., Results: Out of 158 completed trials, only 8% (12 of 158) met inclusion criteria with published results. These 12 trials included a total of 1,568 patients with a mean age of 61 years. Almost half (42%; (5 of 12)) of trials did not report race, while only 17% (2 of 12) of trials reported ethnicity. In trials reporting complete racial data (n = 5), 77% (377 of 493) patients were White, 15% (n = 73) Black or African American, and 4% (n = 19) Asian. American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander patients were severely underrepresented (0.4% and 0.2%, respectively). Of the two trials reporting ethnicity, 94% (479 of 514) patients were Not Hispanic or Latino. Sponsoring body of the trial, trial phase, intervention type, number of trial patients, or mean age of patients were not significantly associated with racioethnic reporting. Notably, no trial reported any measures of socioeconomic status., Conclusion: Our review revealed significant gaps in the reporting of racial, ethnic, and socioeconomic data in MSD clinical trials, with substantial underrepresentation of minority groups. This underrepresentation limits the generalizability of trial findings and may perpetuate health disparities. Coordinated efforts from researchers, clinicians, policymakers, and funding bodies are needed to improve diversity in future trials. Strategies such as targeted outreach, community engagement, and more inclusive eligibility criteria should be implemented to ensure that trial populations better reflect the diversity of MSD patients in the general population., Competing Interests: Declarations. Ethics approval: Being a cross-sectional analysis of published trials, ethics approval was not required to be sought. Competing interests: The authors declare no competing interests. Consent to participate: Being a cross-sectional analysis of published trials, the consent to participate was not required to be sought., (© 2025. The Author(s).)

Background: Chordoma is a rare bone cancer with limited treatment options. Clinical trials are crucial for developing effective therapies, but their success depends on including diverse patient populations. The objective of this study was to systematically evaluate the reporting of racial, ethnic, and socioeconomic diversity in United States clinical trials exploring treatment for chordoma., Methods: A literature search was conducted through PubMed/Medline, Cochrane, Epistemonikos, and ClinicalTrials.gov databases for published US chordoma trials up until 19 August 2024. The data collected included trial characteristics and racial and ethnic data, as well as socioeconomic indicators when available. Methodological Index for Non-Randomized Studies (MINORS) and Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB2) analyses were adopted to assess the methodological quality. The N-1 Chi-squared (χ 2 ) test was implemented to compare the reported racial and ethnic data with the most recent US Census Bureau data., Results: Five trials involving 111 patients (median age: 63 years; 34% female) were included. Four studies (80%) were single-arm non-randomized studies with one study (25%) having a high methodological quality and three (75%) having a moderate quality based on the MINORS analysis. Most patients (91%, n = 82) were White/Caucasian, representing a proportion which was significantly higher than the reported 75% in the US population ( p = 0.0005). Black/African American patients (2%, n = 2) were significantly underrepresented compared to the 14% in the US population ( p = 0.0015). Regarding ethnicity, Hispanic/Latino patients (7%, n = 6) were significantly underrepresented compared to the 20% in the US population ( p = 0.0021). No measures of socioeconomic status were reported., Conclusions: This systematic review highlighted the need for improved racial and ethnic diversity in chordoma trials and the better reporting of socioeconomic data. The underrepresentation of minority groups may obscure potential disparities in disease incidence, treatment access, and clinical outcomes.

Bone mineral density (BMD) is an essential indicator of bone strength and plays a crucial role in the clinical management of various spinal pathologies. Hounsfield units (HUs) calculated from computed tomography (CT) scans are a well-established, effective, and non-invasive method to determine bone density in the lumbar spine when juxtaposed to dual-energy X-ray absorptiometry (DEXA) scans, the gold standard for assessing trabecular bone density. Only recently have studies begun to investigate and establish HUs as a reliable and valid alternative for bone quality assessment in the cervical spine as well. In addition, multiple recent studies have identified cervical HUs as an accurate predictor of cage subsidence, an undesired complication of anterior cervical discectomy and fusion (ACDF) of anterior cervical corpectomy and fusion (ACCF) procedures. Subsidence involves migration of the spinal fusion cage into vertebral bodies, causing a loss of disk space, negatively altering spine alignment, and possibly necessitating further unwanted surgical intervention. Using the PRISMA-ScR checklist and the registered scoping review protocol (INPLASY2024100126), this review explores the current research on the use of cervical spine HU measurements as both a determinant of BMD and as a prognosticator of postoperative subsidence following cervical spine procedures (i.e., ACDFs and ACCFs) with the aim of improving clinical and surgical outcomes.

Objective: Disparities in access and delivery of care have been shown to disproportionately affect certain racial groups. Studies have been conducted to assess these disparities within the spinal metastasis population, but the extent of their effects in the setting of other socioeconomic measures remains unclear. The purpose of this study was to perform a systematic review to understand the effect of racial disparities on outcomes in patients with metastatic spine disease., Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, where a comprehensive online search was performed using Pubmed, Medline, Web of Science, Cochrane, Embase, and Science Direct using MeSH terms related to metastatic spine tumor surgery and racial disparities up to February 2023. Two independent reviewers screened and analyzed articles to include studies assessing the following primary outcomes: clinical presentation, treatment type, postoperative complications, readmission, reoperation, survival and/or mortality, length of hospital stay, discharge disposition, and advance care planning., Results: A total of 13 studies were included in final analysis; 12 were retrospective cohort studies (Level of evidence III) and 1 was a prospective study (Level of evidence II). Postoperative complications were the most studied outcome in 46% of studies (6 of 13), followed by survival in 31% (4 of 13), and treatment type also in 31% (4 of 13). Overall, race was found to be significantly associated with at least one evaluated outcome in 69% of studies (9 of 13). Racial disparities were found in the incidence of cord compression, non-routine discharge, and treatment type in patients with metastatic spine disease. No differences were found on rates of post-operative ambulation, advance care planning, readmission, or survival; inconsistent results were seen for postoperative complications and length of stay. Nine studies (69%) included at least one other measure of socioeconomic status in multivariate analysis, with the two most common being insurance type and income., Conclusions: Although some studies suggest race to be associated with presenting characteristics, treatment type and outcome of patients with spinal metastases, there was significant variability in the inclusion of measures of socioeconomic status in study analyses. As such, the association between race and outcomes in oncologic spine surgery remains unclear., (Published by Elsevier Inc.)

Purpose: This systematic review aimed to collate and synthesize the available literature on the abscopal effect in Glioblastoma multiforme (GBM) neoplasms, focusing on the reported biochemical mechanisms driving the abscopal effect., Methods: A systematic search was conducted in PubMed, Cochrane Database of Systematic Reviews, and Epistemonikos from inception to May 1, 2023. Studies exploring the abscopal effect in GBM were included. The Clinical Relevance Assessment of Animal Preclinical research (RAA) tool was used to assess methodological quality of preclinical studies. Data on preclinical models, biochemical mechanisms, and outcomes were extracted and synthesized systrmatically., Results: Out of a total of 7 studies, five preclinical studies met the inclusion criteria. The studies utilized various in vivo mouse models, including bilateral tumor models and immunohumanized mice. Key biochemical mechanisms identified included immunogenic cell death, danger-associated molecular pattern release, macrophage activation, and enhanced T cell responses. Combinatorial approaches involving oncolytic virotherapy, nanoparticle-based treatments, radiation therapy, and immune checkpoint inhibitors showed promise in inducing abscopal effects. Significant tumor growth inhibition and improved survival were reported in treated animals. However, the RAA analysis highlighted concerns regarding research transparency and internal validity across studies., Conclusions: This systematic review highlighted the potential of the abscopal effect in GBM, demonstrating its ability to enhance anti-tumor immune responses both locally and systemically. The synergistic effects of combinatorial approaches showed promise for improving outcomes. However, the low methodological quality of existing studies underscored the need for more rigorous preclinical research. Future studies should focus on improving research transparency, exploring the abscopal effect in other primary CNS neoplasms, and translating these findings into clinical trials to assess safety and efficacy in humans., Competing Interests: Declarations. Ethical approval: Being a systematic review of published, de-identified preclinical data, ethics approval was exempted from being sought. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures., Materials and Methods: A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects., Results: Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs., Conclusion: There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice., Clinical Relevance Statement: The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures., Key Points: RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures., (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Chordomas are rare sarcomas arising from notochordal tissue and occur most commonly in the spine. The standard of care for chordomas without evidence of metastatic disease generally consists of en bloc resection followed by adjuvant radiotherapy. However, long-term (20-year) survival rates are approximately 30%. Chordomas are generally considered as chemo resistant. Therefore, systemic therapies have rarely been employed. Novel immunotherapies, including antibody therapy and tumor vaccines, have shown promise in early trials, leading to extended progression-free survival and symptom relief. However, the outcomes of larger trials using these vectors are heterogeneous. The aim of this review is to summarize novel chordoma treatments in immune-targeted therapies. The current merits, trial outcomes, and toxicities of these novel immune and targeted therapies, including those targeting vascular endothelial growth factor receptor (VEGFR) targets and the epidermal growth factor receptor (EGFR), will be discussed.

Objective: Hounsfield unit (HU) values measured using CT have been increasingly recognized to stand as a reliable corollary to dual-energy x-ray absorptiometry (DEXA) scores in evaluating bone mineral density. The authors examined the correlation between cervical HU values and DEXA T- and Z-scores and determined novel cervical HU thresholds for determining bone quality classification., Methods: One hundred patients who underwent both cervical spine CT and DEXA, 85 patients who underwent both lumbar CT and DEXA, and 128 patients who underwent cervical and lumbar CT within 24 months at a single institution were included in this retrospective review. Two independent reviewers collected HU values from 3 cervical vertebral levels (C4-6) and 4 lumbar vertebral levels (L1-4), and the averaged values were used. Pearson's correlation coefficient analysis was performed to compare the association of cervical HU values with lumbar HU values and T- and Z-scores. The mean cervical HU values for each DEXA classification were calculated and compared. Receiver operating characteristic (ROC) curves were created to determine the threshold and its sensitivity and specificity for diagnosis., Results: Cervical (C4-6) HU values and average, lumbar, and femoral T- and Z-scores had significant correlations (0.436 > r > 0.274, all p < 0.01). A strong positive correlation between cervical and lumbar HU values was found (r = 0.79, p < 0.01). The average cervical HU value of healthy patients was 361.2 (95% CI 337.1-385.3); of osteopenic patients, 312.1 (95% CI 290.3-333.8); and of osteoporotic patients, 288.4 (95% CI 262.6-314.3). There was a significant difference between the cervical HU values of healthy and osteopenic patients (p = 0.0134) and between those of healthy and osteoporotic patients (p = 0.0304). The cervical HU value of 340.98 was 73.5% specific and 57.9% sensitive for diagnosing osteopenia with an area under the ROC (AUROC) curve of 0.655. The cervical HU value of 326.5 was 88.9% specific and 63.2% sensitive for diagnosing osteoporosis with an AUROC curve of 0.749., Conclusions: This is the second large-scale study and first with a patient population from the United States to show that HU values obtained using cervical CT were significantly correlated with bone quality based on DEXA T- and Z-scores and to establish a cervical HU threshold for determining bone quality classification. These results show that cervical HU values can and should be used to predict poor bone quality in surgical cervical spine patients.

Background: This study sought to identify associations between the Yost Index, a geocoded area neighborhood socioeconomic status (nSES) score, and race/ethnicity with patient refusal of recommended surgery for metastatic bone disease., Methods: Patients with metastatic bone disease were extracted from the Surveillance, Epidemiology, and End Results database. The Yost Index was geocoded using factor analysis and categorized into quintiles using census tract-level American Community Service (ACS) 5-year estimates and seven nSES measures. Multivariable logistic regression models calculated odds ratios (ORs) of refusal of recommended surgery and 95% confidence intervals (CIs), adjusting for clinical covariates., Results: A total of 138,257 patients were included, of which 14,943 (10.8%) were recommended for surgical resection. Patients in the lowest nSES quintile had 57% higher odds of refusing surgical treatment than those in the highest quintile (aOR = 1.57, 95% CI 1.30-1.91, p < 0.001). Patients in the lowest nSES quintile also had a 31.2% higher age-adjusted incidence rate of not being recommended for surgery compared with those in the highest quintile (186.4 vs. 142.1 per 1 million, p < 0.001). Black patients had 34% higher odds of refusing treatment compared with White patients (aOR = 1.34, 95% CI 1.14-1.58, p = 0.003). Advanced age, unmarried status, and patients with aggressive cancer subtypes were associated with higher odds of refusing surgery (p < 0.001)., Conclusions: nSES and race/ethnicity are independent predictors of a patient refusing surgery for metastatic cancer to bone, even after adjusting for various clinical covariates. Effective strategies for addressing these inequalities and improving the access and quality of care of patients with a lower nSES and minority backgrounds are needed., (© 2024. The Author(s).)

The rate of major complications and 30-day mortality after surgery for metastatic spinal tumors is relatively high. While most studies have focused on baseline comorbid conditions and operative parameters as risk factors, there is limited data on the influence of other parameters such as sociodemographic or socioeconomic data on outcomes. We retrospectively analyzed data from 165 patients who underwent surgery for spinal metastases between 2012-2023. The primary outcome was development of major complications (i.e., Clavien-Dindo Grade III-IV complications), and the secondary outcome was 30-day mortality (i.e., Clavien-Dindo Grade V complications). An exploratory data analysis that included sociodemographic, socioeconomic, clinical, oncologic, and operative parameters was performed. Following multivariable analysis, independent predictors of Clavien-Dindo Grade III-IV complications were Frankel Grade A-C, lower modified Bauer score, and lower Prognostic Nutritional Index. Independent predictors of Clavien-Dindo Grade V complications) were lung primary cancer, lower modified Bauer score, lower Prognostic Nutritional Index, and use of internal fixation. No sociodemographic or socioeconomic factor was associated with either outcome. Sociodemographic and socioeconomic factors did not impact short-term surgical outcomes for metastatic spinal tumor patients in this study. Optimization of modifiable factors like nutritional status may be more important in improving outcomes in this complex patient population.

Background: Metastasis to the spinal column is a common complication of malignancy, potentially causing pain and neurologic injury. An automated system to identify and refer patients with spinal metastases can help overcome barriers to timely treatment. We describe the training, optimization and validation of a natural language processing algorithm to identify the presence of vertebral metastasis and metastatic epidural cord compression (MECC) from radiology reports of spinal MRIs., Methods: Reports from patients with spine MRI studies performed between January 1, 2008 and April 14, 2019 were reviewed by a team of radiologists to assess for the presence of cancer and generate a labeled dataset for model training. Using regular expression, impression sections were extracted from the reports and converted to all lower-case letters with all nonalphabetic characters removed. The reports were then tokenized and vectorized using the doc2vec algorithm. These were then used to train a neural network to predict the likelihood of spinal tumor or MECC. For each report, the model provided a number from 0 to 1 corresponding to its impression. We then obtained 111 MRI reports from outside the test set, 92 manually labeled negative and 19 with MECC to test the model's performance., Results: About 37,579 radiology reports were reviewed. About 36,676 were labeled negative, and 903 with MECC. We chose a cutoff of 0.02 as a positive result to optimize for a low false negative rate. At this threshold we found a 100% sensitivity rate with a low false positive rate of 2.2%., Conclusions: The NLP model described predicts the presence of spinal tumor and MECC in spine MRI reports with high accuracy. We plan to implement the algorithm into our EMR to allow for faster referral of these patients to appropriate specialists, allowing for reduced morbidity and increased survival., Competing Interests: One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms., (© 2024 The Author(s).)

Background: Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States., Methods: Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index., Results: Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932)., Conclusions: The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Study Design: This was a single-institutional retrospective cohort study., Objective: Wound infections are common following spine metastasis surgery and can result in unplanned reoperations. A recent study published an online wound complication risk calculator but has not yet undergone external validation. Our aim was to evaluate the accuracy of this risk calculator in predicting 30-day wound infections and 30-day wound reoperations using our operative spine metastasis population., Methods: An internal operative database was used to identify patients between 2012 and 2022. The primary outcomes were 1) any surgical site infection and 2) wound-related revision surgery within 30 days following surgery. Patient details were manually collected from electronic medical records and entered into the calculator to determine predicted complication risk percentages. Predicted risks were compared to observed outcomes using receiver operator characteristic (ROC) curves with areas under the curve (AUC)., Results: A total of 153 patients were included. The observed 30-day postoperative wound infection incidence was 5% while the predicted wound infection incidence was 6%. In ROC analysis, good discrimination was found for the wound infection model (AUC = 0.737; P = 0.024). The observed wound reoperation rate was 5% and the predicted wound reoperation rate was 6%. ROC analysis demonstrated poor discrimination for wound reoperations (AUC = 0.559; P = 0.597)., Conclusions: The online wound-related risk calculator was found to accurately predict wound infections but not wound reoperations within our metastatic spine surgery cohort. We suggest that the model may be clinically useful despite underlying population differences, but further work must be done to generate and validate accurate prediction tools., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Design: Systematic Review and Meta-analysis., Objectives: To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States., Methods: PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients., Results: 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included., Conclusions: AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types., Methods: A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses., Results: Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007)., Conclusions: Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care., Competing Interests: None of the authors report any conflicts of interest relevant to this work., (© 2024 The Author(s).)

Iatrogenic arterial injuries may occur during neurosurgical procedures. Particularly, the vertebral artery may be injured in a high-level cervical spinal fusion case, either during the initial exposure or when placing screws. 1- 3 If such an injury occurs, obtaining hemostatic control and repairing the laceration are of paramount importance. 4, 5 In this technical video, we describe the case of a patient who was undergoing a posterior C1-C2 cervical fusion when the right vertebral artery was injured due to variant anatomy. Using sutures to repair the injury was unsuccessful. Thus, we employed a technique known as crimping, which involves the use of vascular clips to pinch off the site of the tear. This technique is an improvement over existing methods given how quickly and easily it can be performed. In our technical video, we explain how to perform the crimping technique and discuss indications for its use. The patient consented to the procedure., Competing Interests: ContributorshipKainaat Javed and Ryan Holland created the original presentation. Neil Haranhalli and David Altschul provided supervision and revised the presentation. Reza Yassari wrote the script. Ryan Holland did the voiceover while Mousa Hamad did the video editing. All authors approved of the submission. Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis., Methods: This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively., Results: Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21-22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17-20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12-40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48-3.97; p = 0.003)., Conclusions: High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.

Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhages, particularly in the elderly. Despite extensive research regarding cSDH diagnosis and treatment, there is conflicting data on predictors of postoperative mortality (POM). We conducted a large retrospective review of patients who underwent a cSDH evacuation at a single urban institution between 2015 and 2022. Data were collected from the electronic medical record on prior comorbidities, anticoagulation use, mental status on presentation, preoperative labs, and preoperative/postoperative imaging parameters. Univariate and multivariate analyses were conducted to analyze predictors of mortality. Mortality during admission for this cohort was 6.1%. Univariate analysis showed the mortality rate was higher in those presenting with a history of dialysis. In addition, those who presented with altered mental status, were intubated, and lower GCS scores had higher rates of POM. Usage of Coumadin was correlated with higher rates of POM. Examination of preoperative labs showed that patients who presented with anemia or thrombocytopenia had higher POM. Imaging data showed that cSDH volume and greatest dimension were correlated with higher rates of POM. Finally, patients that were not extubated postoperatively had higher rates of POM. Multivariate analysis showed that only altered mental status and being not being extubated postoperatively were correlated with a higher risk of mortality. In summation, we demonstrated that altered mental status and failure to extubate were independent predictors or mortality in cSDH evacuation. Interestingly, patient age was not a significant predictor of mortality., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Estimated postoperative survival is an important consideration during the decision-making process for patients with spinal metastases. Nutritional status has been associated with poor outcomes and limited survival in the general cancer population. The objective of this study was to evaluate the predictive utility of the prognostic nutritional index (PNI) for postoperative mortality after spinal metastasis surgery., Methods: A total of 139 patients who underwent oncologic surgery for spinal metastases between April 2012 and August 2022 and had a minimum 90-day follow-up were included. PNI was calculated using preoperative serum albumin and total lymphocyte count, with PNI < 40 defined as low. The mean PNI of our cohort was 43 (standard deviation: 7.7). The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed., Results: The 90-day mortality was 27% (37/139), and the 12-month mortality was 56% (51/91). After controlling for age, ECOG performance status, total psoas muscle cross-sectional area (TPA), and primary cancer site, the PNI was associated with 90-day mortality [odds ratio 0.86 (95% confidence interval 0.79-0.94); p = 0.001]. After controlling for ECOG performance status and primary cancer site, the PNI was associated with 12-month mortality [OR 0.89 (95% CI 0.82-0.97); p = 0.008]. Patients with a low PNI had a 50% mortality rate at 90 days and an 84% mortality rate at 12 months., Conclusion: The PNI was independently associated with 90-day and 12-month mortality after metastatic spinal tumor surgery, independent of performance status, TPA, and primary cancer site., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: Retrospective cohort., Summary of Background Data: Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited., Objective: To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery., Methods: A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed., Results: Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97-6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36-6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36-4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70-4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively., Conclusions: We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted., Competing Interests: Conflict of Interest All authors of this study report no conflicts of interest and have no disclosures, (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Assessment of nutritional status is fundamental in cancer patients. The objective of this study was to assess the predictive ability of 6 nutritional biomarkers for postoperative mortality and wound infection after metastatic spinal tumor surgery., Methods: A total of 139 patients who underwent oncological surgery for metastatic spine disease between April 2012 and August 2022 and had a minimum follow-up of 90 days were included. Six unique nutritional biomarkers were assessed: Prognostic Nutritional Index (PNI), Nutritional Risk Index (NRI), Controlling Nutritional Status Score (CONUT), total psoas cross-sectional area (TPA), body mass index (BMI), and body weight. Study endpoints were 90-day mortality rate, 12-month mortality rate, and wound infection. The discriminative ability of each of these markers was assessed with the c-statistic. A multivariate analysis was done for each of the biomarkers after a univariate analysis was first performed., Results: The 90-day mortality rate was 27% (37 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.74), NRI (0.75), CONUT (0.71), TPA (0.64), BMI (0.59), and body weight (0.60). The 12-month mortality rate was 56% (51 of 91). The biomarkers and respective c-statistics were as follows: PNI (0.72), NRI (0.73), CONUT (0.70), TPA (0.63), BMI (0.59), and body weight (0.60). The wound infection rate was 8% (11 of 139). The biomarkers and respective c-statistics were as follows: PNI (0.57), NRI (0.53), CONUT (0.55), TPA (0.57), BMI (0.48), and body weight (0.52). The PNI, NRI, and CONUT all predicted 90-day and 12-month mortality after multivariate regression analysis. No association between nutrition and wound infection was found., Conclusions: In this study, nutritional status was associated with postoperative mortality following oncological spine surgery. Three biomarkers predicted outcome independent of variables such as performance status or primary cancer. Future validation of these metrics is needed.

Introduction: Primary CNS leiomyosarcomas are rare, dural-based intracranial or intravertebral tumors seen in immunocompromised patients and are associated with latent EBV infection. They may mimic a meningioma or schwannoma on imaging but their clinical presentation progresses much more rapidly. Often times, these tumors are hard to distinguish from secondary, metastatic leiomyosarcoma., Case Presentation: A 30-year-old female with congenital HIV presented to clinic with shoulder pain, paresthesias of the right upper extremity and gait instability. She was noted to have a contrast enhancing dural-based spinal canal lesion measuring 1.5 cm at the C1 vertebral level on MRI. Surgery was proposed but patient deferred. She represented to our Emergency Department 1 month later with right-sided hemiparesis and difficulty with ambulation. On repeat MRI, the lesion had grown to 2.6 cm. She was taken to the OR emergently for gross total tumor resection. The histopathology demonstrated a primary CNS leiomyosarcoma. MRI scan of the brain revealed an extra-axial right frontal lobe lesion measuring 1.8 cm which was also treated with subtotal surgical resection followed by proton beam radiotherapy., Discussion: Primary CNS leiomyosarcomas should be considered in young immunocompromised patients presenting with dural-based spinal cord tumors. Histopathological studies including EBV testing can definitively make the diagnosis. These tumors have an aggressive nature and need to be treated with complete surgical resection to prevent severe neurological deterioration and adjuvant therapy to prevent recurrence., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Despite the well documented importance and success of interventional pain procedures in the management of painful spine conditions, detractors have questioned their role as part of the care paradigm since their inception. One of the many unexpected consequences of the COVID-19 pandemic in the United States was the forced shut down of elective procedures in early 2020. This caused many patients suffering with pain, who had already been deemed appropriate for an interventional procedure to have to wait an extended period of time. This unprecedented period in modern healthcare provided the opportunity for a long term examination of how this cohort of patients suffering with pain faired while being forced to wait for pain relieving intervention, and to demonstrate the vital importance of these procedures for not only pain relief but for improvement in quality of life. This study will show that an overwhelming number of patients reported that their pain had not improved spontaneously over time, and were anxious to proceed with intervention once given the opportunity., (© 2023 The Authors.)

Study Design: This was a retrospective cohort study., Objective: The objective of this study was to assess the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator performance in patients undergoing surgery for metastatic spine disease., Summary of Background Data: Patients with spinal metastases may require surgical intervention for cord compression or mechanical instability. The ACS-NSQIP calculator was developed to assist surgeons with estimating 30-day postoperative complications based on patient-specific risk factors and has been validated within several surgical patient populations., Materials and Methods: We included 148 consecutive patients at our institution who underwent surgery for metastatic spine disease between 2012 and 2022. Our outcomes were 30-day mortality, 30-day major complications, and length of hospital stay (LOS). Predicted risk, determined by the calculator, was compared with observed outcomes using receiver operating characteristic curves with area under the curve (AUC) and Wilcoxon signed-rank tests. Analyses were repeated using individual corpectomy and laminectomy Current Procedural Terminology (CPT) codes to determine procedure-specific accuracy., Results: Based on the ACS-NSQIP calculator, there was good discrimination between observed and predicted 30-day mortality incidence overall (AUC=0.749), as well as in corpectomy cases (AUC=0.745) and laminectomy cases (AUC=0.788). Poor 30-day major complication discrimination was seen in all procedural cohorts, including overall (AUC=0.570), corpectomy (AUC=0.555), and laminectomy (AUC=0.623). The overall median observed LOS was similar to predicted LOS (9 vs. 8.5 d, P =0.125). Observed and predicted LOS were also similar in corpectomy cases (8 vs. 9 d; P =0.937) but not in laminectomy cases (10 vs. 7 d, P =0.012)., Conclusions: The ACS-NSQIP risk calculator was found to accurately predict 30-day postoperative mortality but not 30-day major complications. The calculator was also accurate in predicting LOS following corpectomy but not laminectomy. While this tool may be utilized to predict risk short-term mortality in this population, its clinical value for other outcomes is limited., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To assess the impact of race on complications following spinal tumor surgery., Methods: Adults with cancer who underwent spine tumor surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program datasets from 2012 to 2016. Clavien-Dindo Grade I-II (minor complications) and Clavien-Dindo Grade III-V (major complications including 30-day mortality) complications were compared between non-Hispanic Whites (NHW) and Black patients. A multivariable analysis was also conducted., Results: Of 1,226 identified patients, 85.9% were NHW (n = 1,053) and 14.1% were Black (n = 173). The overall rate of Grade I-II complications was 16.2%; 15.1% for NHW patients and 23.1% for Black patients ( P = .008). On multivariable analysis, Black patients had significantly higher odds of having a minor complication (OR 1.87; 95% CI, 1.16-3.01; P = .010). On the other hand, the overall rate of Grade III-V complications was 13.3%; 12.5% for NHW patients and 16.2% for Black patients ( P = .187). On multivariable analysis, Black race was not independently associated with major complications (OR 1.26; 95% CI, 0.71-2.23; P = .430). Median length of stay was 8 days (IQR 5-13) for NHW patients and 10 days (IQR 6-15) for Black patients ( P = .011)., Conclusion: Black patients who underwent metastatic spinal tumor surgery were at a significantly increased risk of perioperative morbidity compared to NHW patients independent of baseline and operative characteristics. Major complications did not differ between groups. Race should be further studied in the context of metastatic spine disease to improve our understanding of these disparities.

Objective: Group patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes., Methods: A retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ 2 test and one-way analysis of variance., Results: Five patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0 ± 0.8. Low function/irradiated (LOW + RADS) had preoperative radiation and the lowest Karnofsky scores (56.0 ± 10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0 ± 11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW + NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW + RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW + NEURO (P = 0.003)., Conclusions: Function at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Lymphopenia is often seen in advanced metastatic disease and has been associated with poor postoperative outcomes. Limited research has been done to validate this metric in patients with spinal metastases. The objective of this study was to evaluate the capability of preoperative lymphopenia to predict 30-day mortality, overall survival (OS), and major complications in patients undergoing surgery for metastatic spine tumors., Methods: A total of 153 patients who underwent surgery for metastatic spine tumor between 2012 and 2022 and met the inclusion criteria were examined. Electronic medical record chart review was conducted to obtain patient demographics, comorbidities, preoperative laboratory values, survival time, and postoperative complications. Preoperative lymphopenia was defined as < 1.0 K/μL based on the institution's laboratory cutoff value and within 30 days prior to surgery. The primary outcome was 30-day mortality. Secondary outcomes were OS up to 2 years and 30-day postoperative major complications. Outcomes were assessed with logistic regression. Survival analyses were done using the Kaplan-Meier method with log-rank test and Cox regression. Receiver operating characteristic curves were plotted to classify the predictive ability of lymphocyte count as a continuous variable on outcome measures., Results: Lymphopenia was identified in 47% of patients (72 of 153). The overall 30-day mortality rate was 9% (13 of 153). In logistic regression analysis, lymphopenia was not associated with 30-day mortality (OR 1.35, 95% CI 0.43-4.21; p = 0.609). The mean OS in this sample was 15.6 months (95% CI 13.9-17.3 months), with no significant difference between patients with lymphopenia and those with no lymphopenia (p = 0.157). Cox regression analysis did not show an association between lymphopenia and survival (HR 1.44, 95% CI 0.87-2.39; p = 0.161). The major complication rate was 26% (39 of 153). In univariable logistic regression analysis, lymphopenia was not associated with the development of a major complication (OR 1.44, 95% CI 0.70-3.00; p = 0.326). Finally, receiver operating characteristic curves generated poor discrimination between lymphocyte count and all outcomes, including 30-day mortality (area under the curve 0.600, p = 0.232)., Conclusions: This study does not support prior research that had shown an independent association between low preoperative lymphocyte level and poor postoperative outcomes following surgery for metastatic spine tumors. Although lymphopenia may be used to predict outcomes in other tumor-related surgeries, this metric may not hold a similar predictive capability in the population undergoing surgery for metastatic spine tumors. Further research into reliable prognostic tools is needed.

Purpose: The purpose of this study was to assess the utility of low muscle mass (LMM) in predicting 90-day and 12-month mortality after spinal tumor surgery., Methods: We identified 115 patients operated on for spinal metastases between April 2012 and August 2022 who had available perioperative abdominal or lumbar spine CT scans and minimum 90-day follow-up. LMM was defined as a total psoas muscle cross-sectional area (TPA) at the L4 pedicle level less than 10.5 cm 2 for men and less than 7.2 cm 2 for women based on previously reported thresholds. A secondary analysis was performed by analyzing TPA as a continuous variable. The primary endpoint was 90-day mortality, and the secondary endpoint was 12-month mortality. Multivariate logistic regression analyses were performed., Results: The 90-day mortality was 19% for patients without and 42% for patients with LMM (p = 0.010). After multivariate analysis, LMM was not independently associated with increased odds of 90-day mortality (odds ratio 2.16 [95% confidence interval 0.62 to 7.50]; p = 0.223). The 12-month mortality was 45% for patients without and 71% for patients with LMM (p = 0.024). After multivariate analysis, LMM was not independently associated with increased odds of 12-month mortality (OR 1.64 [95% CI 0.46 to 5.86]; p = 0.442). The secondary analysis showed no independent association between TPA and 90-day or 12-month mortality., Conclusion: Patients with LMM had higher rates of 90-day and 12-month mortality in our study, but this was not independent of other parameters such as performance status, hypoalbuminemia, or primary cancer type., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Disparities among patients with cancer are well documented. Recent studies suggest these disparities also affect patients undergoing metastatic spinal tumor surgery. However, it is unclear whether social factors are associated with ambulatory outcomes or overall survival., Questions/purposes: In patients undergoing metastatic spinal tumor surgery, (1) Are race, Social Vulnerability Index (SVI) score, or insurance status associated with a lower likelihood of postoperative ambulation? (2) Are race, SVI score, or insurance status associated with shorter overall survival?, Methods: Between April 2012 and June 2021, we surgically treated 148 patients for metastatic cord compression or spinal mechanical instability because of cancer. Inclusion criteria were patients with complete demographic, social, oncologic, and follow-up data and patients who were followed until death or for at least 3 months postoperatively. Based on these criteria, 12% (18 of 148) were excluded because they had incomplete data and another 7% (11 of 148) were excluded because they were lost before the minimum study follow-up interval, leaving 80% (119) for analysis. Collected social data included self-reported race (White, Black, Hispanic or Latino, or other), SVI score, and primary insurance (Medicare, Medicaid, or private). The median age of the group was 62 years (interquartile range [IQR] 53 to 70 years), and 58% of patients were men (69 of 119). The race distribution was 45% Black (54 of 119), 32% Hispanic or Latino (38 of 119), 16% White (19 of 119), and 7% other (eight of 119). The median SVI score was 89.8 (IQR 73.8 to 98.5), and 74% of patients (88) were categorized as having high vulnerability. The insurance distribution was as follows: Medicare: 43%, Medicaid: 36%, and private insurance: 21%. The primary outcome variable was complete inability to ambulate postoperatively and the secondary outcome was median overall survival. Exploratory data analysis, univariate and multivariate logistic regression, and univariate and multivariate Cox regression analyses were performed., Results: After controlling for race, SVI score, insurance status, primary cancer, and modified Bauer score, the only factor independently associated with postoperative nonambulation was preoperative nonambulatory status (odds ratio 59.3 [95% confidence interval (CI) 13.2 to 266.1]; p < 0.001). After controlling for variables such as performance status, BMI, primary cancer, modified Bauer score, and insurance status, factors independently associated with survival included Eastern Cooperative Oncology Group performance status (hazard ratio [HR] 1.4 [95% CI 1.1 to 2.0]; p = 0.03), prostate cancer (HR 0.4 [95% CI 0.1 to 0.9]; p = 0.03), and hematologic cancer (HR 0.3 [95% CI 0.1 to 0.8]; p = 0.02). Race, SVI score, and insurance status were not associated with overall survival., Conclusion: In this study, we found no difference in ambulatory outcome for patients based on their race, SVI score, or insurance status. Likewise, no differences in postoperative survival were found. These findings suggest that despite differences in presentation or short-term outcome reported in other investigations, the social factors we explored were not associated with the likelihood of a patient being nonambulatory postoperatively or shorter survival after spinal tumor surgery. Research studies that analyze race as a covariate of interest should take care to explore metrics of socioeconomic deprivation (such as the SVI score) to avoid drawing misleading conclusions., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Objective: Posterior cervical fusion is a common surgical treatment for patients with myeloradiculopathy or regional deformity. Several studies have found increased stresses at the cervicothoracic junction (CTJ) and significantly higher revision surgery rates in multilevel cervical constructs that terminate at C7. The purpose of this study was to investigate the biomechanical effects of selecting C7 versus T1 versus T2 as the lowest instrumented vertebra (LIV) in multisegmental posterior cervicothoracic fusion procedures., Methods: Seven fresh-frozen cadaveric cervicothoracic spines (C2-L1) with ribs intact were tested. After analysis of the intact specimens, posterior rods and lateral mass screws were sequentially added to create the following constructs: C3-7 fixation, C3-T1 fixation, and C3-T2 fixation. In vitro flexibility tests were performed to determine the range of motion (ROM) of each group in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), and to measure intradiscal pressure of the distal adjacent level (DAL)., Results: In FE, selecting C7 as the LIV instead of crossing the CTJ resulted in the greatest increase in ROM (2.54°) and pressure (29.57 pound-force per square inch [psi]) at the DAL in the construct relative to the intact specimen. In LB, selecting T1 as the LIV resulted in the greatest increase in motion (0.78°) and the lowest increase in pressure (3.51 psi) at the DAL relative to intact spines. In AR, selecting T2 as the LIV resulted in the greatest increase in motion (0.20°) at the DAL, while selecting T1 as the LIV resulted in the greatest increase in pressure (8.28 psi) in constructs relative to intact specimens. Although these trends did not reach statistical significance, the observed differences were most apparent in FE, where crossing the CTJ resulted in less motion and lower intradiscal pressures at the DAL., Conclusions: The present biomechanical cadaveric study demonstrated that a cervical posterior fixation construct with its LIV crossing the CTJ produces less stress in its distal adjacent discs compared with constructs with C7 as the LIV. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

Intervertebral cage mispositioning is an uncommon complication of a posterior lumbar corpectomy. Most frequently, cages are placed obliquely, laterally, or protruding. However, there are few reports of implanted cages that fail to contact the adjacent vertebral endplate and thus no descriptions of successful revisions. The objective of this case report is to report a unique case of minimally invasive rescue vertebroplasty with cement augmentation following a lumbar corpectomy that resulted in graft-endplate noncontact in a medically complicated patient A 60-year-old male with a history of active intravenous (IV) drug use, untreated hepatitis C virus (HCV) infection, and chronic malnourishment presented with low back pain. He had a history of vertebral osteomyelitis managed with intravenous antibiotics, although he was noncompliant with infusions. The diagnosis of L2-L3 discitis-osteomyelitis with intradiscal abscess causing cord compression was made using inpatient lumbar imaging. The initial intervention was accomplished with L2 and L3 vertebral corpectomy with decompression and expandable cage placement as well as a T10-pelvis posterior fixation. Despite the resolution of presenting symptoms, routine postoperative radiographs identified noncontact between the inferior surface of the cage and the superior endplate of the L4 vertebral body. Salvage therapy was pursued via fluoroscopy-guided vertebroplasty with cement augmentation to correct cage malposition. Secondary surgical intervention was successful in bringing the intervertebral cage into contact with the adjacent vertebral body. Lower extremity strength improved, and back pain was resolved. The postoperative motor examination remained unchanged after the rescue procedure. Accurate intraoperative cage placement can be difficult in patients with poor bone quality, especially in the setting of ongoing infection and cachexia. For this reason, routine postoperative imaging is crucial to assessing graft complications. In patients who are poor candidates for revision surgery, we demonstrate that an interventional radiology-based approach may be successful in correcting cage mispositioning and preventing further changes during healing and fusion., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Hamad et al.)

Background: Few studies have assessed the impact of race on short-term patient outcomes in the brain metastasis population. The goal of this study is to evaluate the association of race with inpatient clinical presentation, treatment, in-hospital complications, and in-hospital mortality rates for patients with brain metastases (BM)., Method: Using data collected from the National Inpatient Sample between 2004 and 2014, we retrospectively identified adult patients with a primary diagnosis of BM. Outcomes included nonroutine discharge, prolonged length of stay (pLOS), in-hospital complications, and mortality., Results: Minority (Black, Hispanic/other) patients were less likely to receive surgical intervention compared to White patients (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.66-0.74, p  < 0.001; OR 0.88; 95% CI 0.84-0.93, p  < 0.001). Black patients were more likely to develop an in-hospital complication than White patients (OR 1.35, 95% CI 1.28-1.41, p  < 0.001). Additionally, minority patients were more likely to experience pLOS than White patients (OR 1.48; 95% CI 1.41-1.57, p  < 0.001; OR 1.34; 95% CI 1.27-1.42, p  < 0.001). Black patients were more likely to experience a nonroutine discharge (OR 1.25; 95% CI 1.19-1.31, p  < 0.001) and higher in-hospital mortality than White (OR 1.13; 95% CI 1.03-1.23, p  = 0.008)., Conclusion: Our analysis demonstrated that race is associated with disparate short-term outcomes in patients with BM. More efforts are needed to address these disparities, provide equitable care, and allow for similar outcomes regardless of care., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Neuro-Oncology and the European Association of Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Prediction of blood transfusion after adult spinal deformity (ASD) surgery can identify at-risk patients and potentially reduce its utilization and the complications associated with it. The use of artificial neural networks (ANNs) offers the potential for high predictive capability. A total of 1173 patients who underwent surgery for ASD were identified in the 2017-2019 NSQIP databases. The data were split into 70% training and 30% testing cohorts. Eighteen patient and operative variables were used. The outcome variable was receiving RBC transfusion intraoperatively or within 72 h after surgery. The model was assessed by its sensitivity, positive predictive value, F1-score, accuracy (ACC), and area under the curve (AUROC). Average patient age was 56 years and 63% were female. Pelvic fixation was performed in 21.3% of patients and three-column osteotomies in 19.5% of cases. The transfusion rate was 50.0% (586/1173 patients). The best model showed an overall ACC of 81% and 77% on the training and testing data, respectively. On the testing data, the sensitivity was 80%, the positive predictive value 76%, and the F1-score was 78%. The AUROC was 0.84. ANNs may allow the identification of at-risk patients, potentially decrease the risk of transfusion via strategic planning, and improve resource allocation.

Chronic back and leg pain are leading causes of disability worldwide. The purpose of this study was to compare the care in a unidisciplinary (USC) versus multidisciplinary (MSC) spine clinic, where patients are evaluated by different specialists during the same office visit. Adult patients presenting with a chief complaint of back and/or leg pain between June 2018 and July 2019 were assessed for eligibility. The main outcome measures included the first treatment recommendations, the time to treatment order, and the time to treatment occurrence. A 1:1 propensity score-matched analysis was performed on 874 patients (437 in each group). For all patients, the most common recommendation was physical therapy (41.4%), followed by injection (14.6%), and surgery (9.7%). Patients seen in the MSC were more likely to be recommended injection (p < 0.001) and less likely to be recommended surgery as first treatment (p = 0.001). They also had significantly shorter times to the injection order (log-rank test, p = 0.004) and the injection occurrence (log-rank test, p < 0.001). In this study, more efficient care for patients with back and/or leg pain was delivered in the MSC setting, which was evidenced by the shorter times to the injection order and occurrence. The impact of the MSC approach on patient satisfaction and health-related quality-of-life outcome measures warrants further investigation.

Study Design: This was retrospective cohort study., Purpose: The current investigation uses a large, multi-institutional dataset to compare short-term morbidity and mortality rates between current smokers and nonsmokers undergoing thoracolumbar fusion surgery., Overview of Literature: The few studies that have addressed perioperative complications following thoracolumbar fusion surgeries are each derived from small cohorts from single institutions., Materials and Methods: A retrospective study was conducted on thoracolumbar fusion patients in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2016). The primary outcome compared the rates of overall morbidity, severe postoperative morbidity, infections, pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), transfusions, and mortality in smokers and nonsmokers., Results: A total of 57,677 patients were identified. 45,952 (78.8%) were nonsmokers and 12,352 (21.2%) smoked within 1 year of surgery. Smokers had fewer severe complications (1.6% vs. 2.0%, P = 0.014) and decreased discharge to skilled nursing facilities (6.3% vs. 11.5%, P < 0.001) compared to nonsmokers. They had lower incidences of transfusions (odds ratio [OR] = 0.9, confidence interval [CI] = 0.8-1.0, P = 0.009) and DVT (OR = 0.7, CI = 0.5-0.9, P = 0.039) as well as shorter length of stay (LOS) (OR = 0.9, CI = 0.9-0.99, P < 0.001). They had a higher incidence of postoperative pneumonia (OR = 1.4, CI = 1.1-1.8, P = 0.002). There was no difference in the remaining primary outcomes between smoking and nonsmoking cohorts., Conclusions: There is a positive correlation between smoking and postoperative pneumonia after thoracolumbar fusion. The incidence of blood transfusions, DVT, and LOS was decreased in smokers. Early postoperative mortality, severe complications, discharge to subacute rehabilitation facilities, extubation failure, PE, SSI, and return to OR were not associated with smoking., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Craniovertebral Junction and Spine.)

Case: A 54-year-old woman with chronic lumbar radiculopathy due to grade II spondylolisthesis at lumbar 4 to 5 developed acute cauda equina syndrome (CES) after an elective lumbar decompression, and fusion was delayed because of statewide bans on elective procedures during the pandemic. The diagnosis was made largely through telehealth consultation and eventually prompted urgent neurosurgical intervention., Conclusion: This case report illustrates a rare presentation of acute CES and highlights some of the challenges of practicing clinical medicine in the midst of a pandemic., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B503)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: It is well established that insurance status is a mediator of disease management, treatment course, and clinical outcomes in cancer patients. Our study assessed differences in clinical presentation, treatment course, mortality rates, and in-hospital complications for patients admitted to the hospital with late-stage cancer - specifically, metastatic spine disease (MSD), by insurance status., Methods: The United States National Inpatient Sample (NIS) database (2012-2014) was queried to identify patients with visceral metastases, metastatic spinal cord compression (MSCC) or pathological fracture of the spine in the setting of cancer. Clinical presentation, type of intervention, mortality rates, and in-hospital complications were compared amongst patients by insurance coverage (Medicare, Medicaid, commercial or unknown). Multivariable logistical regression and age sensitivity analyses were performed., Results: A total of 48,560 MSD patients were identified. Patients with Medicaid coverage presented with significantly higher rates of MSCC (p < 0.001), paralysis (0.008), and visceral metastases (p < 0.001). Patients with commercial insurance were more likely to receive surgical intervention (OR 1.43; p < 0.001). Patients with Medicaid < 65 had higher rates of prolonged length of stay (PLOS) (OR 1.26; 95% CI, 1.01-1.55; p = 0.040) while both Medicare and Medicaid patients < 65 were more likely to have non-routine discharges. In-hospital mortality rates were significantly higher for patients with Medicaid (OR 2.66; 95% CI 1.20-5.89; p = 0.016) and commercial insurance (OR 1.58; 95% CI 1.09-2.27;p = 0.013) older than 65., Conclusion: Given the differing severity in MSD presentation, mortality rates, and rates of PLOS by insurance status, our results identify disparities based on insurance coverage., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Estimating complications in oncological spine surgery is challenging. The objective of this study was to compare the accuracy of three scoring systems for predicting perioperative morbidity after surgery for spinal metastases. One-hundred and five patients who underwent surgery between 2013 and 2019 were included in this study. All patients had scores retrospectively calculated using the New England Spinal Metastasis Score (NESMS), Metastatic Spinal Tumor Frailty Index (MSTFI), and Anzuategui scoring systems. The main outcome measure was development of a medical complication (minor or major) within 30 days of surgery. The predictive ability for each system was assessed using receiver operating characteristic analysis and calculations of the area under the curve (AUC). The average age for all patients was 61 years and 61/105 patients (58.1%) were male. The most common primary tumor origins were hematologic (23.8%), prostate (16.2%), breast (14.3%), and lung (13.3%). The overall 30-day complication rate was 36.2% and the rate of major complications was 21.9%. Among all patients who underwent oncological spine surgery, the NESMS score had the highest AUC for 30-day overall (AUC 0.64; 95% CI, 0.53 - 0.75) and major morbidity (AUC 0.68; 95% CI, 0.54- 0.81) in our population. However, the accuracy did not meet the threshold for clinical utility. Future prospective validation of these systems in other populations is encouraged., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective review of a prospectively collected national database., Objective: To evaluate the predictive value of hypoalbuminemia on outcomes in surgical spine oncology patients., Summary of Background Data: It is well documented that patients with hypoalbuminemia (albumin <3.5) have significantly higher rates of surgical morbidity and mortality than patients with normal albumin (>3.5 g/dl). We evaluated outcomes for metastatic oncologic spine surgery patients based on pre-operative albumin levels., Materials and Methods: Patients who underwent surgery for metastatic spine disease were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. Three groups were established: patients with normal albumin (>3.5 g/dl), mild hypoalbuminemia (2.6 g/dl - 3.4 g/dl), and severe hypoalbuminemia (<=2.5 g/dl). A multivariate analysis was used to assess the association between albumin levels and mortality within 30 days of surgical intervention., Results: A total of 700 patients who underwent surgery for metastatic spinal disease and had pre-operative albumin levels available were identified; 64.0% had normal albumin (>3.5 g/dl), 29.6% had mild hypoalbuminemia, and 6.4% had severe hypoalbuminemia. The overall 30-day mortality was 7.6% for patients with normal albumin, 15.9% for patients with mild hypoalbuminemia, and 44.4% for patients with severe hypoalbuminemia. On multivariate analysis, patients with mild hypoalbuminemia (OR 1.7 95% CI: 1.0-3.0 p = 0.05) and severe hypoalbuminemia (OR 6.2 95% CI: 2.8-13.5 p < 0.001) were more likely to expire within 30 days compared to patients with preoperative albumin above 3.5 g/dl., Conclusion: In this study, albumin level was found to be an independent predictor of 30-day mortality in patients who underwent operative intervention for metastatic spinal disease. Patients with severe hypoalbuminemia had a 7-fold increased risk when compared with those who had normal albumin. While these findings need to be validated by future studies, we believe they will prove useful for preoperative risk stratification and surgical decision-making., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Study Design: Retrospective single-institution study., Objective: The aim of this study was to determine the relationship between patients' insurance status and the likelihood for them to be recommended various spine interventions upon evaluation in our neurosurgical clinics., Summary of Background Data: Socioeconomically disadvantaged populations have worse outcomes after spine surgery. No studies have looked at the differential rates of recommendation for surgery for patients presenting to spine surgeons based on socioeconomic status., Methods: We studied patients initially seeking spine care from spine-fellowship trained neurosurgeons at our institution from July 1, 2018 to June 30, 2019. Multivariable logistic regression was used to assess the association between insurance status and the recommended patient treatment., Results: Overall, 663 consecutive outpatients met inclusion criteria. Univariate analysis revealed a statistically significant association between insurance status and treatment recommendations for surgery (P < 0.001). Multivariate logistic regression demonstrated that compared with private insurance, Medicare (odds ratio [OR] 3.54, 95% confidence interval [CI] 1.21-7.53, P = 0.001) and Medicaid patients (OR 2.46, 95% CI 1.21-5.17, P = 0.014) were more likely to be recommended for surgery. Uninsured patients did not receive recommendations for surgery at significantly different rates than patients with private insurance., Conclusion: Medicare and Medicaid patients are more likely to be recommended for spine surgery when initially seeking spine care from a neurosurgeon. These findings may stem from a number of factors, including differential severity of the patient's condition at presentation, disparities in access to care, and differences in shared decision making between surgeons and patients.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Systematic review and meta-analysis., Objective: To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4., Methods: A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement., Results: A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08., Conclusion: Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.