BACKGROUND Predicting survival of patients with spinal metastases would help stratify treatments from aggressive to palliation. OBJECTIVE To evaluate whether sarcopenia predicts survival in patients with lung, breast, prostate, or multiple myeloma spinal metastases. METHODS Psoas muscle measurements in patients with spinal metastasis were taken from computed tomography scans at 2 time points: at first episode of stereotactic body radiation therapy (SBRT) and from the most recent scan available. Overall survival and hazard ratios were calculated with multivariate cox proportional hazards regression analyses. RESULTS In 417 patients with spinal metastases, 40% had lung cancer, 27% breast, 21% prostate, and 11% myeloma. Overall survival was not associated with age, sex, ethnicity, levels treated, or SBRT volume. Multivariate analysis showed patients in the lowest psoas tertile had shorter survival (222 d, 95% CI = 185-323 d) as compared to the largest tertile (579 d, 95% CI = 405-815 d), (HR1.54, P = .005). Median psoas size as a cutoff value was also strongly predictive for survival (HR1.48, P = .002). Survival was independent of tumor histology. The psoas/vertebral body ratio was also successful in predicting overall survival independent of tumor histology and gender (HR1.52, P < .01). Kaplan–Meier survival curves visually represent survival (P = .0005). CONCLUSION In patients with spine metastases, psoas muscle size as a hallmark of frailty/sarcopenia is an objective, simple, and effective way to identify patients who are at risk for shorter survival, regardless of tumor histology. This information can be used to help with surgical decision making in patients with advanced cancer, as patients with small psoas sizes are at higher risk of death.

BACKGROUND Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care. OBJECTIVE To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis. METHODS A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity. RESULTS Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity. CONCLUSION In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates.

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Following partial AVM embolization, PI, RI are unchanged and flow velocities in feeder arteries also remain unchanged likely due to redistribution of flow through residual nidus. Thus, staged management of AVMs is unlikely to increase outflow resistance and offers a safe treatment strategy.

Epilepsy is a neurological disorder that affects more than 70 million people globally. A considerable proportion of epilepsy is resistant to anti-epileptic drugs (AED). For patients with drug-resistant epilepsy (DRE), who are not eligible for resective or ablative surgery, neuromodulation has been a palliative option. Since the approval of vagus nerve stimulation (VNS) in 1997, expansion to include other modalities, such as deep brain stimulation (DBS) and responsive neurostimulation (RNS), has led to improved seizure control in this population. In this article, we discuss the current updates and emerging trends on neuromodulation for epilepsy.

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Atlanto-occipital dislocation (AOD) is a craniocervical injury that has serious neurological consequences and is often fatal. High-speed blunt trauma, such as motor vehicle accidents, that extend and put traction on the head can cause this injury. The current recommendation for diagnosis is to measure the condyle-C1 interval (CCI) using a computed tomography (CT) scan in the coronal plane and more recently in the sagittal plane. We report the case of a patient who suffered a motor vehicle accident and had concomitant AOD and atlanto-axial dislocation. In this particular case, the CCI method failed to diagnose AOD and the diagnosis was made using the basion-dens interval (BDI) and other methodologies, as well as the presence of ligamentous disruption at the craniovertebral junction (CVJ) on magnetic resonance imaging (MRI).A 19-year-old female suffered a motor vehicle accident in which she was ejected from the car. Her neck was immobilized on the scene and she was brought to the emergency department complaining of neck pain. CT of the cervical spine showed concomitant atlanto-occipital and atlanto-axial dissociation. MRI of the cervical spine confirmed the diagnosis with total ligamentous disruption at the CVJ and distraction of the atlanto-axial joints bilaterally. While the CCI was normal, the BDI was diagnostic of AOD.The current recommendations for using the CCI interval method may not diagnose AOD in the presence of associated atlanto-axial dislocation. Other methodologies should be employed including BDI and basion-axial interval (BAI) as well as MR imaging showing ligamentous disruption.