BackgroundProximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery in elderly patients is markedly influenced by osteoporosis causing additional vertebral fracture and loosening of pedicle screws (PS). This study aimed to investigate the association between mean bone density represented in Hounsfield units (HU) on spinal computed tomography (CT) and revision surgery for PJK or postoperative additional vertebral fracture following ASD surgery in elderly patients.MethodsThe subjects were 54 ASD patients aged 65 years or older who were treated with correction and fusion surgery of four or more levels and could be followed for 2 years or longer. Bone density was measured before surgery using lumbar dual-energy X-ray absorptiometry (DXA) and spinal CT in all patients. The patients were divided into group A (n = 14) in which revision surgery was required for PJK or additional vertebral fracture and group B (n = 40) in which revision surgery was not required. We retrospectively investigated incidences of PJK, additional vertebral fracture, and PS loosening, perioperative parameters, radiographic parameters before and after surgery, and osteoporosis treatment administration rate.ResultsNo significant difference was noted in young adult mean (YAM) on DXA between groups A and B, respectively (P = 0.62), but the mean bone densities represented in HU of the T8 (P = 0.002) and T9 (P = 0.01) vertebral bodies on spinal CT were significantly lower in group A, whereas those of the L4 (P = 0.002) and L5 (P = 0.01) vertebral bodies were significantly higher in group A. The incidence of PJK was not significantly different (P = 0.07), but the incidence of additional vertebral fracture was significantly higher in group A (P < 0.001). The incidences of uppermost PS loosening within 3 months after surgery were 71% and 40% in groups A and B, respectively (P = 0.04).ConclusionsIn elderly patients who required revision surgery, the mean bone densities of vertebral bodies at T8 and T9 were significantly lower. The mean bone density represented in HU on spinal CT may be useful for risk assessment of and countermeasures against revision surgery after ASD surgery in elderly patients.

BackgroundSurgeries performed for metastatic spinal tumor are mostly palliative and are controversial for patients with short life expectancy. We investigated whether palliative posterior spinal stabilization surgery with postoperative multidisciplinary therapy results in improvement of life prognosis and activities of daily living (ADL) in patients with metastatic spinal tumor.MethodsThe subjects were 55 patients who underwent palliative posterior-only instrumentation surgery for metastatic spinal tumor at our hospital between 2012 and 2015. Postoperative survival, early paralysis improvement, ADL improvement, and rate of discharge to home were examined.ResultsThe patients included 37 males and 18 females, and the mean age at the time of surgery was 66.8 years old. The mean Tokuhashi score was 7.1, the mean spinal instability neoplastic score (SINS) was 9.4, and the epidural spinal cord compression scale (ESCCS) was grade 3 in 20 patients (36.3%). The mean Barthel index for ADL was 48.7. The median postoperative survival time determined using the Kaplan-Meier method was 12.0 months (95% confidence interval 2.4–21.5). Regarding improvement of paralysis, the modified Frankel scale was improved by one grade or more or grade E was maintained in 35 patients (63.6%), whereas paralysis aggravated in 2 (3.6%). In surgery, conventional posterior decompression and fixation were applied in 31 patients (56.3%), and minimally invasive spine stabilization was applied in 24 (43.6%). Postoperative chemotherapy was performed in 31 patients (56.3%), radiotherapy was used in 38 (69.0%), and a bone-modifying agent was administered in 39 (70.2%). Regarding ADL, the mean Barthel index improved from 48.5 before surgery to 74.5 after surgery. Thirty-seven patients (67.2%) were discharged to home.ConclusionsADL improved and allowed discharge to home, and postoperative adjuvant therapy could be administered at a high rate in patients who received palliative posterior spinal stabilization surgery. Survival time extended beyond the preoperative life expectancy in many patients. Patients with a metastatic spinal tumor have short life expectancy and paralysis caused by spinal instability and spinal cord compression. However, multidisciplinary therapy including palliative posterior spinal stabilization surgery with reduced invasiveness and postoperative adjuvant therapy are effective in these patients.

BackgroundPosterior decompression and stabilization plays significant roles in palliative surgery for metastatic spinal tumor. However, the indication for addition of posterior decompression have not been examined. The purpose of this study was to investigate a retrospective cohort of outcomes of metastatic spinal tumor treated with minimally invasive spine stabilization (MISt) with or without posterior decompression.MethodsThe subjects were 40 patients who underwent MISt using percutaneous pedicle screws for metastatic spinal tumor, including 20 patients treated with stabilization alone (group A) and 20 patients with added posterior decompression (group B). We analyzed baseline characteristics, postoperative survival time, and perioperative factors such as neurological outcomes, Barthel Index, VAS, and rate of discharge to home.ResultsThe mean ages were 70 and 66 years old (P = 0.06), the mean revised Tokuhashi scores were 7.2 and 5.8 (P = 0.1), the mean spinal instability neoplastic scores (SINS) were 10.5 and 9.0 (P = 0.04), and the mean Barthel Index for ADL were 65.5 and 41.0 (P = 0.06) in groups A and B, respectively. The median postoperative survival time did not differ significantly between groups A and B (12.0 vs. 6.0 months, P = 0.09). Patients in group A had a significantly shorter operation time (166 vs. 232 min, P = 0.004) and lower intraoperative blood loss (120 vs. 478 mL, P < 0.001). Postoperative paralysis (P = 0.1), paralysis improvement rate (P = 0.09), postoperative Barthel Index (P = 0.06), and postoperative VAS (P = 0.6) did not differ significantly between the groups. The modified Frankel classification improved from D1 or D2 before surgery to D3 or E after surgery in 4 of 10 cases (40%) in group A and 8 of 8 patients (100%) in group B (P = 0.01). Significantly more patients were discharged to home in group A (P = 0.02), whereas significantly more patients died in the hospital in group B (P = 0.02).ConclusionsPatients treated without decompression had a shorter operation time, less blood loss, a higher rate of discharge to home, and lower in-hospital mortality, indicating a procedure with lower invasiveness. MISt without decompression is advantageous for patients with D3 or milder paralysis, but decompression is necessary for patients with D2 or severer paralysis.

Background Therapeutic intervention has recently been actively performed for metastatic spine tumor even though spinal cord paralysis is not clearly observed, but there has been no report in which the degree of spinal cord compression by tumor was taken into consideration for the paralysis-preventing effect of treatment. Thus, we investigated the neurological outcome after treatment of patients with spinal cord compression in a state of impending paralysis. Methods A retrospective cohort study. The subjects were 88 patients with epidural spinal cord compression (ESCC) scale 1b or severer compression with American Spinal Injury Association (ASIA) E spinal metastasis. The neurological outcome after the therapeutic intervention was investigated at regular intervals until death. The therapeutic intervention was posterior decompression and stabilization in 18 patients, stabilization without posterior decompression in 15, and radiotherapy in 55 patients (3 groups). Results The ASIA aggravation group was comprised of 15 patients, and the severity of paralysis was ASIA A in 3, B in 3, C in 6, and D in 3. Paralysis appeared in 16.7% in the posterior decompression and stabilization group, 13.3% in the posterior stabilization without decompression group, and 18.8% in the radiotherapy group. In the transverse view, the incidence was high in cases with advancement to the intervertebral foramen and circumferential-type advancement, and paralysis developed in more than 20% of ESCC 1c or severer cases. Factors influencing neurological aggravation were investigated, but there was no significant factor. Conclusion In ESCC 1b or severer cases with ASIA E spinal metastasis, paralysis aggravated after therapeutic intervention in 16.7% in the posterior decompression and stabilization group, 13.3% in the stabilization without decompression group, and 16.7% in the radiotherapy group. There was no significant factor influencing the development of paralysis.

Purpose Minimally invasive spine stabilization (MISt) using percutaneous pedicle screws plays a significant role in palliative surgery for metastatic spinal tumors. However, few studies have investigated surgical outcomes based on the epidural spinal cord compression scale (ESCCS). The purpose of this study was to examine outcomes of metastatic spinal tumors as evaluated by ESCCS in patients treated by MISt. Methods The subjects were 56 patients who underwent MISt for metastatic spinal tumors, including 34 patients with ESCCS 2 or milder (group A) and 22 patients with ESCCS 3 (group B). We analyzed baseline characteristics, perioperative factors and clinical results such as postoperative survival time, neurological outcomes, Barthel Index for activities of daily living (ADL), visual analogue scale (VAS), and the rate of discharge to home. Results The baseline age (P=0.07), tumor diagnosis (P=0.23), spinal level of compression (P=0.35), American Spinal Injury Association classification (P=0.49), revised Tokuhashi score (P=0.92), spinal instability neoplastic score (P=0.28), VAS (P=0.35), Barthel Index (P=0.07), American Society of Anesthesiologists physical status classification (P=0.76), and type of surgery (P=0.40) did not differ significantly between the two groups. The median postoperative survival time did not differ significantly between the groups (12.0 versus 15.0 months, P=0.60). Neurological improvement by at least 1 grade or maintenance of grade E was favorable in group A. Patients in group A had less posterior decompression (P=0.006), a higher rate of chemotherapy (P=0.009), a higher postoperative Barthel Index (P=0.04), and a higher rate of discharge to home (P=0.01) and no patients died in the hospital (P=0.004). Conclusions No significant difference was noted in the postoperative survival time between the 2 groups. Patients in the ESCCS 2 or milder group had favorable neurological improvement, higher rates of chemotherapy, better postoperative ADL, and the higher rate of discharge to home.