Neurosurgery concepts: Key perspectives on imaging characteristics of spinal metastases, surgery for low back pain, anesthesia for disc surgery, and laminectomy versus laminectomy and fusion for lumbar spondylolisthesis
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, South Korea
- Department of Neurosurgery, Beaumont Hospital, Grosse Pointe, MI, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Texas Children's Hospital, Houston, Texas, United States
- Department of Neurological Surgery, Loyola University Chicago, Stritch School of Medicine, Illinois, United States
- Department of Neurosurgery, University of California, San Diego School of Medicine, San Diego, California, United States
- Department of Neurosurgery, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Stanford School of Medicine, Stanford, California, United States
- 0Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
- 1Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington DC, United States
- 2Seton Brain and Spine Institute Neurosurgery, Kyle, Texas, United States
- 3Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
DOI:10.4103/2152-7806.198736Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Carlito Lagman, Lawrance K. Chung, Luke Macyszyn, Winward Choy, Zachary A. Smith, Nader S. Dahdaleh, Angela M. Bohnen, Jin M. Cho, Chaim B. Colen, Edward Duckworth, Anand V. Germanwala, Peter Kan, Alexander A. Khalessi, Chae-Yong Kim, Sandi Lam, Gordon Li, Michael Lim, Jonathan H. Sherman, Vincent Y. Wang, Gabriel Zada, Isaac Yang. Neurosurgery concepts: Key perspectives on imaging characteristics of spinal metastases, surgery for low back pain, anesthesia for disc surgery, and laminectomy versus laminectomy and fusion for lumbar spondylolisthesis. 19-Jan-2017;8:9
How to cite this URL: Carlito Lagman, Lawrance K. Chung, Luke Macyszyn, Winward Choy, Zachary A. Smith, Nader S. Dahdaleh, Angela M. Bohnen, Jin M. Cho, Chaim B. Colen, Edward Duckworth, Anand V. Germanwala, Peter Kan, Alexander A. Khalessi, Chae-Yong Kim, Sandi Lam, Gordon Li, Michael Lim, Jonathan H. Sherman, Vincent Y. Wang, Gabriel Zada, Isaac Yang. Neurosurgery concepts: Key perspectives on imaging characteristics of spinal metastases, surgery for low back pain, anesthesia for disc surgery, and laminectomy versus laminectomy and fusion for lumbar spondylolisthesis. 19-Jan-2017;8:9. Available from: http://surgicalneurologyint.com/surgicalint_articles/neurosurgery-concepts-key-perspectives-on-imaging-characteristics-of-spinal-metastases-surgery-for-low-back-pain-anesthesia-for-disc-surgery-and-laminectomy-versus-laminectomy-and-fusion-for-lumba/
Keywords: Laminectomy, low back pain, neoplasm metastasis, spinal cord, spinal fusion, spondylolisthesis
IMAGING CHARACTERISTIC ANALYSIS OF METASTATIC SPINE LESIONS FROM BREAST, PROSTATE, LUNG, AND RENAL CELL CARCINOMAS FOR SURGICAL PLANNING: OSTEOLYTIC VERSUS OSTEOBLASTIC
Study Question: What are the computed tomography (CT) imaging characteristics of common spine metastases? The authors of this study retrospectively reviewed CT images for patients treated for metastatic spine disease at their institution from 2009 to 2012.[
Osteolytic lesions demonstrate destructive loss of both cancellous and cortical bone and are often well-demarcated. Osteoblastic lesions are hyperdense, expansile, and also well-demarcated. Osteolytic lesions are associated with spinal instability and pathologic fractures, and may require fusion and instrumentation. Osteoblastic lesions are associated with spinal and foraminal stenosis, and may require decompression. The authors recommend preoperative CT of the spine to facilitate surgical planning.
Perspective: Advances in imaging have enhanced our understanding of the radiologic profiles of pathologies, both outside and within the neural axis. Neurosurgeons use imaging characteristics to focus differential diagnoses and ultimately guide management. In the spine, identification of bony metastases and organization of these lesions into those amenable to fusion versus decompressive surgery becomes increasingly important.
The incidence of spinal metastases remains high in patients with breast, lung, renal cell, and prostate cancer. This study highlights the osteolytic nature of breast, lung, and RCC metastases and the osteoblastic tendency of prostate metastases. Despite the sample size being relatively small, the lesions were evenly distributed among the most common spinal metastases. The retrospective nature of this study is sufficient for characterization of the lesions. However, future studies should aim to validate the trends described here using larger prospective cohorts.
Recent studies investigating the molecular mechanisms underlying osteolytic and osteoblastic lesions have largely focused on breast and prostate cancers, respectively. These studies provide insight into the radiologic patterns observed in this paper. Breast cancer cells are known to secrete parathyroid hormone related protein (PTHrP), tumor necrosis factor α, interleukins, leukemia inhibitory factor, receptor activator of nuclear factor kappa-B ligand (RANKL), and transforming growth factor beta (TGF-β), which can all stimulate osteolysis.[
Summary Written by: Carlito Lagman, MD
THE ROLE OF SURGERY FOR TREATMENT OF LOW BACK PAIN: INSIGHTS FROM THE RANDOMIZED CONTROLLED SPINE PATIENT OUTCOMES RESEARCH TRIALS
Study Question: In patients with low back pain, what is the role of surgical intervention for disc herniation, degenerative spondylolisthesis and spinal stenosis?
The authors reviewed recent findings from the Spine Patient Outcomes Research Trial (SPORT) I–III, randomized clinical trials from 13 sites across the country over a 5-year period, which investigated the clinical efficacy of surgery for three common causes of low back pain (i.e., disc herniation [DH], degenerative spondylolisthesis [DS], and spinal stenosis [SS]).[
SPORT I investigated surgical efficacy for lumbar DH for 501 patients with image-confirmed lumbar intervertebral DH and persistent radiculopathy for at least 6 weeks. Patients were randomly assigned to either open discectomy or nonoperative care. Although adherence to assigned treatment was poor, intention-to-treat analysis showed substantial improvement in all primary and secondary outcomes. However, when comparing between treatment groups, primary outcomes were not significant, while some secondary outcomes (SBI and self-reported progress at 1 year) were significantly improved for the surgical group. As-treated analyses showed significant improvement with surgery in all primary outcomes. These differences persisted at 8-year follow-up.
SPORT II investigated surgical efficacy for DS of 304 patients in a randomized cohort and 303 patients in an observational cohort for patients with image-confirmed DS and persistent symptoms for at least 12 weeks. Treatment was either decompressive laminectomy (with or without fusion) or nonoperative care. Similar to SPORT I, a high crossover rate was observed. Intention-to-treat analysis showed no difference in primary outcomes. As-treated analyses showed significant improvement for surgery in all primary and secondary outcomes up to 2 years that persisted up to the 4-year follow-up.
SPORT III investigated surgical efficacy for SS for 289 patients in a randomized cohort and 365 patients in an observational cohort for patients with image-confirmed SS without spondylolisthesis and persistent symptoms for at least 12 weeks. Treatment was either decompressive laminectomy or nonoperative care. Similar to SPORT I and II there was a high rate of crossover. Intention-to-treat analysis showed significant improvement on the SF-36 bodily pain index of 7.8 (95% CI: 1.5–14.1) for surgery, but not on the SF-36 physical function index or ODI. As-treated analyses showed a significant improvement for surgery in all primary and secondary outcomes up to 2 years, with the differences in primary outcomes persisting up to the 4-year follow-up.
Perspective: Back pain remains a common cause of morbidity in the United States. The Center for Disease Control and Census Bureau data indicate that back and spine disorders are the second most common cause of disability in the United States. There is significant controversy regarding the role of surgical management of these disorders, particularly in the face of rapidly rising health care cost causing increased scrutiny on the number of spine surgeries performed. The results from the SPORT trials indicate that appropriate surgery remains an effective treatment for select patients with DH, DS, and SS, and that these results were both statistically and clinically significant. However, the extensive crossover that was seen in each trial (approaching 50% in certain cases) indicates that offering a previously noneffective, nonoperative management essentially negated the randomization within the study. If a randomized trial were to be attempted in the future, care must be chosen to establish a viable alternative nonsurgical treatment. Despite the surgical efficacy that was demonstrated in the SPORT studies, these findings should not be misapplied to the general patient seeking evaluation. The SPORT trials had strict inclusion and exclusion criteria that may limit their applicability. Nevertheless, these studies represent a significant attempt at elucidating the surgical efficacy for common spine disorders and reducing public stigmas against spine surgery.
Written by: Lawrance K. Chung, BS and Luke Macyszyn, MD, MA
GENERAL ANESTHESIA VERSUS COMBINED EPIDURAL/GENERAL ANESTHESIA FOR ELECTIVE LUMBAR SPINE DISC SURGERY: A RANDOMIZED CLINICAL TRIAL COMPARING THE IMPACT OF THE TWO METHODS UPON THE OUTCOME VARIABLES
Study Question: How do intraoperative and postoperative factors differ after general anesthesia (GA) and combined general/epidural anesthesia (CEG) for elective lumbar spine disc surgery?
The authors performed a prospective, randomized controlled trial enrolling a total of 88 patients undergoing elective spine disc surgery.[
Mean intraoperative blood loss was less in the CEG group (p = 0.002), which led to less blood being transfused (p = 0.006), when compared to the GA group. Mean percentage of isoflurane used was less in the CEG group (p < 0.001) when compared to the GA group. Mean pain scores were less in the CEG group (p < 0.01). In the CEG group, analgesia requirements, time to first rescue analgesia, and total amount of morphine used were also less (p < 0.001), longer (p = 0.001) and less (p = 0.001), respectively, when compared to the GA group. This data suggests that CEG may reduce intraoperative blood loss and anesthesia requirements, provide better pain control, and decrease the risk of postoperative complications.
Perspective: Lumbar spine disc surgery is most often performed under GA, with the primary advantage being airway patency. This study highlights the potential advantages of CEG in patients undergoing the aforementioned procedures. The sample size and randomized nature of the study support the conclusions. Furthermore, the authors performed multivariate analyses to control for confounders such as age, sex, and weight, particularly in their analysis of intraoperative blood loss. However, it is unclear whether these same analyses were performed for the other outcome measures. It is also possible that some patients may be better suited for GA, such as those on chronic anticoagulation therapy, for whom there is a high risk of epidural hematoma. Moreover, it is unclear whether the reported benefit of less intraoperative blood loss (with CEG) outweighs the risk of epidural hematoma. Prudent cost-benefit analyses are necessary to determine whether the cost of added epidural anesthesia justifies the advantages described. Comparison of GA versus spinal anesthesia would be valuable because this approach is very important to older patients who may experience more complications (related to multisystem disease) under general anesthesia compared to spinal anesthesia. Moreover, the fear of complications related to general anesthesia is ever present in patients suffering from spinal stenosis, disc disease, and/or foraminal stenosis, and this has the potential to influence patient preference regarding anesthesia.
Summary Written by: Winward Choy, BA and Zachary A. Smith, MD
LAMINECTOMY PLUS FUSION VERSUS LAMINECTOMY ALONE FOR LUMBAR SPONDYLOLISTHESIS AND A RANDOMIZED, CONTROLLED TRIAL OF FUSION SURGERY FOR LUMBAR SPINAL STENOSIS
Study Question: Is lumbar decompression a sufficient operation for patients with lumbar spinal stenosis in the setting of degenerative spondylolisthesis?
Two randomized control studies were recently published in the New England Journal of Medicine that compared decompression only to decompression and fusion in patients who harbor lumbar spinal stenosis in the setting of a stable degenerative spondylolisthesis.
The first study by Ghogawala et al. randomized a total of 66 patients with lumbar spinal stenosis and spondylolisthesis.[
The second study by Forsth et al. included 247 patients who had lumbar stenosis.[
Perspective: The conclusion from the Ghogawala study was that decompression and fusion surgery for patients with lumbar spinal stenosis in the setting of stable spondylolisthesis is superior than decompression only, whereas the conclusion from the Forsth study was that fusion surgery is unnecessary for patients with stenosis and spondylolisthesis because decompression has similar outcomes and is sufficient. The Ghogawala study was difficult to follow and was less clear in its results. The Forsth paper was an excellent study with good long-term follow-up in almost all patients.
The conflicting results between these two randomized studies are a reflection of the heterogeneity of degenerative lumbar spondylolisthesis. Patients with stable spondylolisthesis on flexion and extension X-rays may have predisposition to biomechanical instability in the presence of a healthy preserved intervertebral disk and bilateral facet edema. Patients with spondylolisthesis who have disk collapse and bridging osteophytes are not predisposed to biomechanical instability following decompression. Moreover, in both the studies, the laminectomy and fusions were performed utilizing traditional open techniques. At present, the use of minimally invasive spinal surgery techniques has minimized blood loss, surgical time, and hospital length of stay.
In conclusion, patient specific factors should be taken into consideration when deciding between decompression or decompression and fusion surgery for lumbar stenosis and degenerative spondylolisthesis.
Summary Written by: Nader S. Dahdaleh, MD and Isaac Yang, MD
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Conflicts of interest
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