Aims. The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression. Patients and Methods. The medical records of 135 patients with complete paralysis due to neoplastic cord compression were retrospectively reviewed. Potential factors including the timing of surgery, muscular tone, and tumour characteristics were analyzed in relation to neurological recovery using logistical regression analysis. The association between neurological recovery and survival was analyzed using a Cox model. A nomogram was formulated to predict recovery. Results. A total of 52 patients (38.5%) achieved American Spinal Injury Association Impairment Scale (AIS) D or E recovery postoperatively. The timing of surgery (p = 0.003) was found to be significant in univariate analysis. In multivariate analysis, surgery within one week was associated with better neurological recovery than surgery within three weeks (p = 0.002), with a trend towards being associated with a better neurological recovery than surgery within one to two weeks (p = 0.597) and two to three weeks (p = 0.055). Age (p = 0.039) and muscle tone (p = 0.018) were also significant predictors. In Cox regression analysis, good neurological recovery (p = 0.004), benign tumours (p = 0.039), and primary tumours (p = 0.005) were associated with longer survival. Calibration graphs showed that the nomogram did well with an ideal model. The bootstrap-corrected C-index for neurological recovery was 0.72. Conclusion. In patients with complete paralysis due to neoplastic spinal cord compression, whose treatment is delayed for more than 48 hours from the onset of symptoms, surgery within one week is still beneficial. Surgery undertaken at this time may still offer neurological recovery and longer survival. The identification of the association between these factors and neurological recovery may help guide treatment for these patients. Cite this article: Bone Joint J 2019;101-B:872–879

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure. . A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks. A ‘terminal event’ or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation. Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months. Cite this article: Bone Joint J 2013;95-B:1121–6

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC. Retrospective analysis. All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15. Neurological outcome and survival. A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery. The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%. There was no difference in neurological outcome between the 3 groups. There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score

Background and Purpose. Intervertebral disc (IVD) degeneration is a prominent cause of low back pain. IVD cells expressing angiopoietin-1 receptor Tie2 represent a progenitor cell population which decreases with progression of IVD degeneration. Homing of mesenchymal stem cells (MSCs) is a physiological mechanism aiming to enhance the regenerative capacity of the IVD. The purpose of this study was to assess the effect of MSC homing on the Tie2 positive IVD progenitor cell population, the IVD cell viability, and the proliferative phenotype of the IVD cells. Methods and Results. Human MSCs were isolated from bone marrow aspirates and labelled with fluorescent dye. Whole IVDs with endplates were harvested from bovine tails; MSCs were placed on the endplates. Human traumatic, degenerative and healthy IVD tissues were obtained from patients and organ donors. MSCs were added onto tissue samples. After 5 days, IVD cells were isolated. Percentages of Tie2 positive, DAPI positive (dead) and Ki-67 positive (proliferative) IVD cells were determined. MSC homing or co-culture significantly increased the proportion of Tie2 positive progenitor IVD cells in bovine and 7/10 human IVDs, decreased the fraction of dead IVD cells in bovine and 7/10 human IVDs, and induced a proliferative phenotype in bovine and 5/6 human IVDs. Conclusion. Stimulation of bovine and human IVDs by MSC homing resulted in an enhanced population of Tie2 positive IVD progenitor cells, induced a proliferative response and reduced IVD cell death. Hence, the interaction with recruited MSCs may contribute to an improved survival of IVD cells, helping to reverse or slow down an ongoing degenerative process. Conflicts of interest: The authors declare no conflicts of interest. Sources of funding: AO Foundation and AOSpine International

Studies on recurrent disc herniation quote rates of recurrence without regard to the times of recurrence and the influence of longer follow-up. Our objective was to assess the use of survival analysis to measure the rate of revision after lumbar microdiscectomy. We undertook a retrospective analysis of the hospital records of 993 patients who underwent lumbar microdiscectomy over a period of ten years. After calculating the overall rate of revision for the mean length of follow-up, we carried out a survival analysis using the life-table method. During the study period 49 patients had a revision microdiscectomy. This gave an overall rate of revision of 4.9% at a mean follow-up of 5.25 years. Using survival analysis, the rate of revision was 7.9% at a follow-up of ten years when the number at risk was 84. Survival analysis gives a more accurate estimation of the true rate of recurrence for patients undergoing lumbar microdiscectomy. The method allows better comparison between different interventions for disc herniation

Between January 1990 and December 2000 we carried out 226 SB Charité III disc replacements for lumbar disc degeneration in 160 patients. They were reviewed at a mean follow-up of 79 months (31 to 161) to determine the clinical and radiological outcome. The clinical results were collected by an independent observer, who was not involved in patient selection, treatment or follow-up, using a combination of outcome measures, including the Oswestry Disability Index. Pain was recorded using a visual analogue score, and the most recent radiographs were reviewed. Survival of the device was analysed by the Kaplan-Meier method and showed a cumulative survival of 35% at 156 months when radiological failure was taken as the endpoint. The mean improvement in the Oswestry disability index scores after disc replacement was 14% (6% to 21%) and the mean improvement in the pain score was 1.6 (0.46 to 2.73), both falling below the clinically significant threshold. Removal of the implant was required in 12 patients, four because of implant failure. These poor results indicate that further use of this implant is not justified

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival. We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years. There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients). Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3. rd. of chondrosarcomas of the spine occured below 40 years of age and 3/4. th. in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival. The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry. The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively. Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series

Fractures of the odontoid peg are common spinal injuries in the elderly. This study compares the survivorship of a cohort of elderly patients with an isolated fracture of the odontoid peg versus that of patients who have sustained a fracture of the hip or wrist. A six-year retrospective analysis was performed on all patients aged > 65 years who were admitted to our spinal unit with an isolated fracture of the odontoid peg. A Kaplan–Meier table was used to analyse survivorship from the date of fracture, which was compared with the survivorship of similar age-matched cohorts of 702 consecutive patients with a fracture of the hip and 221 consecutive patients with a fracture of the wrist.

A total of 32 patients with an isolated odontoid fracture were identified. The rate of mortality was 37.5% (n = 12) at one year. The period of greatest mortality was within the first 12 weeks. Time made a lesser contribution from then to one year, and there was no impact of time on the rate of mortality thereafter. The rate of mortality at one year was 41.2% for male patients (7 of 17) compared with 33.3% for females (5 of 15).

The rate of mortality at one year was 32% (225 of 702) for patients with a fracture of the hip and 4% (9 of 221) for those with a fracture of the wrist. There was no statistically significant difference in the rate of mortality following a hip fracture and an odontoid peg fracture (p = 0.95). However, the survivorship of the wrist fracture group was much better than that of the odontoid peg fracture group (p < 0.001). Thus, a fracture of the odontoid peg in the elderly is not a benign injury and is associated with a high rate of mortality, especially in the first three months after the injury.

Cite this article: Bone Joint J 2014;96-B:88–93.

The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make difficult decisions in the management of patients presenting with spinal metastases. A prospective cohort study of 199 consecutive patients presenting with spinal metastases, treated with either surgery and/or radiotherapy, was used to compare the three systems. Cox regression, Nagelkerke’s R² and Harrell’s concordance were used to compare the systems and find their best predictive items. The three systems were equally good in terms of overall prognostic performance. Their most predictive items were used to develop the Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient of determination than any of these three scores. A bootstrap procedure was used to internally validate this score and determine its prediction optimism.

The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and general condition (GC): OSRI = PTP + (2 – GC).

This simple score can predict life expectancy accurately in patients presenting with spinal metastases. It will be helpful in making difficult clinical decisions without the delay of extensive investigations.

Cite this article: Bone Joint J 2013;95-B:210–16.

Aims. Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas. Methods. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Results. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Conclusion. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival. Cite this article: Bone Joint J 2023;105-B(5):575–582

Aims. The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS). Methods. We included 28 patients with multiple LCH involving the spine treated between January 2009 and August 2021. Kaplan-Meier methods were applied to estimate overall survival (OS) and PFS. Univariate Cox regression analysis was used to identify variables associated with PFS. Results. Patients with multiple LCH involving the spine accounted for 15.4% (28/182 cases) of all cases of spinal LCH: their lesions primarily involved the thoracic and lumbar spines. The most common symptom was pain, followed by neurological dysfunction. All patients presented with osteolytic bone destruction, and 23 cases were accompanied by a paravertebral soft-tissue mass. The incidence of vertebra plana was low, whereas the oversleeve-like sign was a more common finding. The alkaline phosphatase was significantly higher in patients with single-system multifocal bone LCH than in patients with multisystem LCH. At final follow-up, one patient had been lost to follow-up, two patients had died, three patients had local recurrence, six patients had distant involvement, and 17 patients were alive with disease. The median PFS and OS were 50.5 months (interquartile range (IQR) 23.5 to 63.1) and 60.5 months (IQR 38.0 to 73.3), respectively. Stage (hazard ratio (HR) 4.324; p < 0.001) and chemotherapy (HR 0.203; p < 0.001) were prognostic factors for PFS. Conclusion. Pain is primarily due to segmental instability of the spine from its destruction by LCH. Chemotherapy can significantly improve PFS, and radiotherapy has achieved good results in local control. The LCH lesions in some patients will continue to progress. It may initially appear as an isolated or single-system LCH, but will gradually involve multiple sites or systems. Therefore, long-term follow-up and timely intervention are important for patients with spinal LCH. Cite this article: Bone Joint J 2023;105-B(6):679–687

Aims. The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. Methods. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. Results. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. Conclusion. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction. Cite this article: Bone Joint J 2023;105-B(2):172–179

Background. Chronic low back pain is strongly linked to degeneration of the intervertebral disc (IVD), which currently lacks any targeted treatments. This study explores NPgel, a biomaterial combined with notochordal cells (NC), developmental precursor cells, as a potential solution. NCs, known for anti-catabolic effects on IVD cells, present a promising avenue for regenerating damaged IVD tissue. Methods. Bovine IVDs underwent enzymatic degeneration before NPgel (+/- NC) injection. Degenerated bovine IVDs were cultured under biomechanical loading for 21 days. Histology and immunohistochemistry assessed NC survival, phenotype, and matrix production. Within an in vivo sheep pilot study, NPgel (+/- NC) was injected into degenerated IVDs, blood was taken, and immune cell activation was monitored via flow cytometry over three months post-injection. Results. Within the ex vivo model, IVDs injected with NPgel (+/- NC) exhibited increased matrix expression and deposition. Viable NCs were detected post-culture, indicating survival and matrix production. In the in vivo model, NPgel injection into sheep IVDs did not significantly increase activation of immune cells compared to controls, suggesting no systemic inflammatory effects. Conclusion. NPgel, combined with NCs, shows promise for IVD regeneration. Ex vivo findings indicate NPgel supports NC survival and matrix production. Moreover, in vivo results demonstrate the absence of systemic immunogenic responses post-NPgel injection. This suggests NPgel's potential as a carrier for NCs in IVD regeneration therapy. These findings underscore NPgel's candidacy for further investigation in addressing chronic low back pain associated with IVD degeneration. Subsequent research, including long-term efficacy and safety evaluations, is imperative for clinical translation. Conflicts of interest. There are no conflicts of interest. Sources of funding. iPSpine, grant # 825925, Horizon 2020

Aims. This study aimed to evaluate the incidence and prognosis of patients with spinal metastasis as the initial manifestation of malignancy (SM-IMM). Patients and Methods. We retrospectively reviewed the electronic medical records of 338 patients who underwent surgical treatment for metastatic spinal disease. The enrolled patients were divided into two groups. The SM-IMM group included patients with no history of malignancy whose site of primary malignancy was diagnosed after the identification of spinal metastasis. The other group included patients with a history of treatment for primary malignancy who then developed spinal metastasis (SM-DTM). The incidence of SM-IMM by site of primary malignancy was calculated. The difference between prognoses after surgical treatment for SM-IMM and SM-DTM was established. Results. The median follow-up period was 11.5 months (interquartile range (IQR) 3.2 to 13.4) after surgical treatment. During the follow-up period, 264 patients died; 74 patients survived. The SM-IMM group consisted of 94 patients (27.8%). The site of primary malignancy in the SM-IMM group was lung in 35/103 patients (34.0%), liver in 8/45 patients (17.8%), kidney in 10/33 patients (30.3%), colorectum in 3/29 patients (10.3%), breast in 3/22 patients (13.6%), prostate in 3/10 patients (30%), thyroid in 4/8 patients (50%), and ‘other’ in 28/88 patients (31.8%). On Kaplan–Meier survival analysis, the SM-IMM group showed a significantly longer survival than the SM-DTM group (p = 0.013). The mean survival time was 23.0 months (95% confidence interval (CI) 15.5 to 30.5) in the SM-IMM group and 15.5 months (95% CI 11.8 to 19.2) in the SM-DTM group. Conclusion. Of the 338 enrolled patients who underwent surgical treatment for spinal metastasis, 94 patients (27.8%) underwent surgical treatment for SM-IMM. The SM-IMM group had an acceptable prognosis with surgical treatment. Cite this article: Bone Joint J 2019;101-B:1379–1384

Aims. With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values. Methods. We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected. Results. In total, 65 patients were aged < 70 years (mean 59.6 years; 32 to 69) and 36 patients were aged ≥ 70 years (mean 75.9 years; 70 to 90). In both groups, the PS improved from PS3 to PS1 by spine surgery, the mean BI improved from < 60 to > 80 points, and the mean EQ-5D score improved from 0.0 to > 0.7 points. However, no significant differences were found in the improvement rates and values of the PS, BI, and EQ-5D score at any time points between the two groups. The PS, BI, and EQ-5D score improved throughout the follow-up period in approximately 90% of patients in each group. However, the improved PS, BI, and EQ-5D scores subsequently deteriorated in some patients, and the redeterioration rate of the EQ-5D was significantly higher in patients aged ≥ 70 than < 70 years (p = 0.027). Conclusion. Palliative surgery for spinal metastases improved the PS, activities of daily living, and quality of life, regardless of age. However, clinicians should be aware of the higher risk of redeterioration of the quality of life in advanced-age patients. Cite this article: Bone Joint J 2020;102-B(12):1709–1716

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To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

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Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

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The prevalence of scoliosis is not known in patients with idiopathic short stature, and the impact of treatment with recombinant human growth hormone on those with scoliosis remains controversial. We investigated the prevalence of scoliosis radiologically in children with idiopathic short stature, and the impact of treatment with growth hormone in a cross-sectional and retrospective cohort study.

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Frailty has been gathering attention as a factor to predict surgical outcomes. However, the association of frailty with postoperative complications remains controversial in spinal metastases surgery. We therefore designed a prospective study to elucidate risk factors for postoperative complications with a focus on frailty.