Purpose The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our aim was to analyse the actual survival time of patients treated for metastatic spinal cord compression (MSCC) in comparison with the predicted survival based on the revised Tokuhashi score. This would thereby allow us to determine the overall predictive value of this scoring system. Methods This study was a semi-prospective clinical study of all patients with MSCC presenting to our unit over 8 years-data from October 2003 to December 2009 were collected retrospectively and from December 2009, all data collected prospectively to October 2011. Patients were divided into three groups-Group 1 (Tokuhashi score 0-8, n = 84), Group 2 (Tokuhashi score 9-11, n = 83) and Group 3 (Tokuhashi score 12-15, n = 34). Data collected included demographic data, primary tumour histology, surgery type and complications, neurological outcome (Frankel grade) and survival. Results A total of 233 patients with MSCC were managed surgically in our unit during this time. Out of these complete data were available on 201 patients for analysis.Mean age of patients was 61 years (range 18-86; 127 M, 74 F). The primary tumour type was Breast (n = 29, 15 %), Haematological (n = 28, 14 %), Renal (n = 26, 13 %), Prostate (n = 26, 13 %), Lung (n = 23, 11 %), Gastro-intestinal (n = 11, 5 %), Sarcoma (n = 9, 4 %) and others (n = 49, 24 %). All patients included in the study had surgical intervention in the form of decompression and stabilisation. Posterior decompression and stabilisation was performed in 171 patients (with vertebrectomy in 31), combined anterior and posterior approaches were used in 18 patients and 12 had an anterior approach only. The overall complication rate was 19 % (39/201)-the most common being wound infection (n = 15, 8 %). There was no difference in the neurological outcome (Frankel grade) between Groups 1 and 2 (p = 0.34) or Groups 2 and 3 (p = 0.70). However, there was a significant difference between Groups 1 and 3 (p = 0.001), with Group 3 having a significantly better neurological outcome. Median survival was 93 days in Group 1, 229 days in Group 2 and 875 days in Group 3 (p = 0.001). The predictive value between the actual and predicted survival was 64 % (Group 1), 64 % (Group 2) and 69 % (Group 3). The overall predictive value of the revised Tokuhashi score using Cox regression for all groups was 66 %. Conclusion We would conclude that although the predictive value of the Tokuhashi score in terms of survival time is at best modest (66 %), the fact that there were statistically significant differences in survival between the groups looked at in this paper indicates that the scoring system, and the components which it consists of, are important in the evaluation of these patients when considering surgery.

Purpose Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the 'timing of surgery' is an important factor in survival and neurological outcome in patients with MSCC. Methods All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups-those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications. Results Patients' age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24-48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (-0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups. Conclusions Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.

Purpose To present the results of the surgical management of metastatic renal cell tumours of the spine with cord compression who underwent pre-operative embolisation. Methods We conducted a retrospective cohort study of all embolised vascular metastatic renal cell tumours of the spine that underwent urgent surgical intervention over a 7-year period (2005)(2006)(2007)(2008)(2009)(2010)(2011). All medical notes, images and angiography/embolisation details were studied. We recorded the timing (immediate vs. delayed) and grade of embolisation and compared this to the estimated blood loss (EBL); extent of metastatic spinal cord compression (using the Tomita score and Bilsky scores) was also compared to EBL. Finally, neurological (Frankel grade), surgical outcome and complications were reviewed in all patients. Results During the study period, we operated on 25 emergency patients with metastatic renal cell carcinoma causing spinal cord compression who had received preoperative embolisation (mean age 59.6 (24-78) years; 8 females, 17 males). All but one of our patients had hypervascularisation/arterio-venous fistulae on angiography. We were able to achieve greater than 90 % embolisation in the majority (17/25, 68 %) The estimated blood loss was 1,696 (400-5,000) ml; mean operating time was 276 (90-690) min and an average of 2.3 (0-7) units of whole blood was transfused. Nine patients had a posterior only decompression/stabilisation, nine patients had a posterior decompression ± cement augmentation, six had combined anterior/posterior procedures and one had anterior corpectomy/reconstruction alone. There was no statistical difference in the EBL between immediate versus delayed surgery after embolisation or the grade of embolisation. Immediate surgery after embolisation and interestingly less complete embolisation showed a trend towards less EBL. The extent of the tumour as graded by the Bilsky score correlated with increased EBL (p = 0.042). No complications occurred during the embolisation procedure. The surgical complication rate was 32 % (8/25) including two major complications (septicaemia (1) and metal work failure (2)) and five minor complications. Postoperatively, 52 % (13/25) had no change in neurological status, 36 % (9/25) improved by at least one Frankel grade and 12 % (3/25) had neurological deterioration by one Frankel grade. The average survival following surgery was 14.1 (0.5-72) months. Conclusion Blood loss (mean 1,696 ml) and complications (32 %) remain a concern in the operative treatment of vascular metastatic spinal cord compression. Most patients remained the same neurologically or improved by at least 1 grade (22/25, 88 %). Paradoxically, greater embolisation showed a trend to more blood loss which could be due to more extensive surgery in this group, a rebound 'reperfusion' phenomena or even the presence of arterio-venous fistulae. Interestingly, we also found that the extent of the tumour, as graded by the Bilsky score, correlated with increased blood loss suggesting that more extensive...

The utility of nanotechnology in medicine, specifically within the field of orthopedics, is a topic of extensive research. Our review provides a unique comprehensive overview of the current and potential future uses of nanotechnology with respect to orthopedic sub-specialties. Nanotechnology offers an immense assortment of novel applications, most notably the use of nanomaterials as scaffolds to induce a more favorable interaction between orthopedic implants and native bone. Nanotechnology has the capability to revolutionize the diagnostics and treatment of orthopedic surgery, however the long-term health effects of nanomaterials are poorly understood and extensive research is needed regarding clinical safety.

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Most surgeons believe that Asians have a low risk of developing venous thromboembolism (VTE) and routine thromboprophylaxis therapy is not required after major orthopaedic trauma. This study evaluates the postoperative risk of VTE in Indian patients sustaining pelvi-acetabular injury. Fifty-six patients with pelvi-acetabular injury, who underwent open reduction and internal fixation, were prospectively evaluated for VTE in the postoperative period. They were evaluated, both clinically and radiologically (pulmonary CT angiography and indirect venography of lower limb and pelvis veins), until six weeks after surgery. A total of 16 patients developed VTE, of which 12 had proximal deep vein thrombosis (DVT), ten had pulmonary embolism (PE) and only two had distal DVT. Six patients with proximal DVT had associated PE. The risk of development of VTE among Indian patients after pelvi-acetabular injury is high (28.6%) with increasing chances of proximal DVT and PE; hence, administration of routine thromboprophylaxis is fully justified in them.

Aim:We undertook this study involving 200 peri- and postmenopausal women to determine the prevalence of osteoporosis, and in turn increase the awareness, education, prevention, and treatment of osteoporosis.Setting and Design:Postgraduate Institute of Medical Education and Research, UT Chandigarh, India, and a clinical study.Materials and Methods:A detailed medical, obstetrical, menstrual, and drug history was recorded in a proforma designated for the study. Height and weight was measured, weight-bearing exercise was assessed, and sunlight exposure per day for each woman was recorded. Food intake was estimated by using the 24-hour dietary recall method, and calcium and vitamin D consumption pattern was assessed. Bone mineral density (BMD) at postero-anterior lumbar spine and dual femurs was assessed by densitometer. Women were classified according to the WHO criteria.Statistical Analysis Used:Student's t-test, multiple logistic regression analysis.Results:The prevalence of low BMD was found in more than half of this population (53%). The mean age in group I (normal BMD) was found to be 50.56 ± 5.74 years as compared to 52.50 ± 5.94 in group II with low BMD (P=0.02). The two groups were similar with respect to parity, education, socioeconomic status, family history of osteoporosis, hormone replacement therapy, and thyroid disorders. 46.8% of the women in group I and 33% of the women in group II had low physical activity and there was no statistically significant difference in sunlight exposure between the groups. Parity or the number of children and type of menopause was not seen to have much association with low BMD in our study. Lack of exercise and low calcium diet were significantly associated with low BMD. Multiple logistic regression analysis showed that age, exercise, menopause, and low calcium diet acted as significant predictors of low bone density.Conclusion:The findings from the study suggest the need for large community-based studies so that high-risk population can be picked up and early interventions and other life style changes can be instituted if there is delay in implementing national or international health strategies to tackle this increasing global health problem. Strategies to identify and manage low BMD in the primary care setting need to be established and implemented.

In our series, the incidence of MSCC due to an unknown primary was 6 %. They had similar overall outcome (neurology post-operatively, complications and survival) to those patients with MSCC from a known primary. Our experience would suggest that we need to treat these patients expeditiously with thorough evaluation and urgent treatment.