Citations

Background While clinical and angiographic risk factors for intracranial aneurysm instability are well established, it is reasonable to postulate that intra-aneurysmal hemodynamics also have a role in aneurysm instability. Objective To identify hemodynamic characteristics that differ between radiologically unstable and stable unruptured intracranial aneurysms. Materials and methods 12 pairs of unruptured intracranial aneurysms with a 3D rotational angiographic set of images and followed up longitudinally without treatment were studied. Each pair consisted of one stable aneurysm (no change on serial imaging) and one unstable aneurysm (demonstrated growth of at least 1 mm diameter or ruptured during follow-up) of matching size (within 10%) and locations. Patient-specific computational fluid dynamics models were created and run under pulsatile flow conditions. Relevant hemodynamic and geometric variables were calculated and compared between groups using the paired Wilcoxon test. Results The area of the aneurysm under low wall shear stress (low shear stress area (LSA)) was 2.26 times larger in unstable aneurysms than in stable aneurysms (p=0.0499). The mean aneurysm vorticity was smaller by a factor of 0.57 in unstable aneurysms compared with stable aneurysms (p=0.0499). No statistically significant differences in geometric variables or shape indices were found. Conclusions This pilot study suggests there may be hemodynamic differences between unstable and stable unruptured cerebral aneurysms. In particular, the area under low wall shear stress was larger in unstable aneurysms. These findings should be considered tentative until confirmed by future larger studies.

Purpose To attempt to visualize the ligament with standard 1.5‐tesla magnetic resonance imaging (MRI) in the acute anterior cruciate ligament (ACL)–torn knee, and if it is visible, attempt to characterize it as torn or intact at its femoral, meniscal, and tibial attachment sites. Methods This was a retrospective MRI study based on arthroscopic findings of a known ACL tear in 72 patients between the years 2006 and 2010. Patients all had hamstring ACL reconstructions, no concomitant lateral collateral ligament, or posterolateral corner injury based on imaging and physical examination, and had a preoperative 1.5‐tesla MRI scan with standard sequences performed within 3 weeks of the injury. Two fellowship‐trained musculoskeletal radiologists retrospectively reviewed the preoperative MRI for visualization of the anterolateral ligament (ALL) for concomitant tears. Inter‐ and intraobserver reliability was calculated. Learning effect was analyzed to determine if radiologists' agreement improved as reads progressed. Results Both radiologists were able to visualize the ALL in 100% of the scans. Overall, ALL tears were noted in 26% by radiologist 1 and in 62% by radiologist 2. The agreement between the ligament being torn or not had a kappa of 0.54 between radiologists. The agreements in torn or not torn between radiologists in the femoral, meniscal, and tibial sites were 0.14, 0.15, and 0.31. The intraobserver reliability by radiologist 1 for femoral, meniscal, and tibial tears was 0.04, 0.57, and 0.54 respectively. For radiologist 2, they were 0.75, 0.61, and 0.55. There was no learning effect noted. Conclusions ALL tears are currently unable to be reliably identified as torn or intact on standard 1.5‐tesla MRI sequences. Proper imaging sequences are of crucial importance to reliably follow these tears to determine their clinical significance. Level of Evidence Level IV, therapeutic case series study.

Purpose To develop a system prognostic of outcome in those undergoing allogeneic hematopoietic cell transplantation (allo HCT) for myelodysplastic syndrome (MDS). Patients and Methods We examined 2,133 patients with MDS undergoing HLA-matched (n = 1,728) or -mismatched (n = 405) allo HCT from 2000 to 2012. We used a Cox multivariable model to identify factors prognostic of mortality in a training subset (n = 1,151) of the HLA-matched cohort. A weighted score using these factors was assigned to the remaining patients undergoing HLA-matched allo HCT (validation cohort; n = 577) as well as to patients undergoing HLA-mismatched allo HCT. Results Blood blasts greater than 3% (hazard ratio [HR], 1.41; 95% CI, 1.08 to 1.85), platelets 50 × 109/L or less at transplantation (HR, 1.37; 95% CI, 1.18 to 1.61), Karnofsky performance status less than 90% (HR, 1.25; 95% CI, 1.06 to 1.28), comprehensive cytogenetic risk score of poor or very poor (HR, 1.43; 95% CI, 1.14 to 1.80), and age 30 to 49 years (HR, 1.60; 95% CI, 1.09 to 2.35) were associated with increased hazard of death and assigned 1 point in the scoring system. Monosomal karyotype (HR, 2.01; 95% CI, 1.65 to 2.45) and age 50 years or older (HR, 1.93; 95% CI, 1.36 to 2.83) were assigned 2 points. The 3-year overall survival after transplantation in patients with low (0 to 1 points), intermediate (2 to 3), high (4 to 5) and very high (≥ 6) scores was 71% (95% CI, 58% to 85%), 49% (95% CI, 42% to 56%), 41% (95% CI, 31% to 51%), and 25% (95% CI, 4% to 46%), respectively (P < .001). Increasing score was predictive of increased relapse (P < .001) and treatment-related mortality (P < .001) in the HLA-matched set and relapse (P < .001) in the HLA-mismatched cohort. Conclusion The proposed system is prognostic of outcome in patients undergoing HLA-matched and -mismatched allo HCT for MDS.

Context: Psychosocial factors can impact lung transplant outcomes. However, it is currently unknown whether abuse survivorship influences lung transplant survival. Objective: To characterize the abuse history of adult lung transplant patients and determine whether such history is associated with mortality. Patients and Other Participants: Adult lung transplant recipients evaluated from 2000 to 2004. Main Outcome Measures: The main outcome was post-lung transplantation survival. The secondary outcomes included demographic, transplantation, or psychological assessment differences between those with a history of abuse survivorship and those without. Results: Thirty-three lung transplant recipients (35.5% male, median age: 55 years) were included. A history of abuse survivorship was common (24.2%) and was associated with decreased survival following lung transplantation ( P = .003). There was no difference in sex, marital status, or smoking history between abuse survivors and those who denied being the victim of abuse. Abuse survivors had a higher Personality Assessment Screener total score, a measure of maladaptive personality traits ( P = .02). Conclusion: Abuse survivorship is common in lung transplant patients and associated with increased posttransplant mortality and increased maladaptive personality traits. This preliminary evidence suggests that lung transplant patients should be screened for abuse history and provided with appropriate treatment of survivorship issues to potentially improve their health outcomes from transplantation.

Introduction Primary tumors of the spine requiring enbloc resection are rare. Most published reports are small and focus on disease free survival and recurrence rates. Very few studies focus on the various anterior and posterior reconstructive options and subsequent outcomes with respect to fusion rates and need for revision due to hardware failure. The objective of this review was to (1) summarize the published literature and (2) report the failure rates of various anterior and posterior reconstructive techniques after enbloc resection of spinal tumors and (3) supplement the deficiencies in the available published literature with expert opinion for reconstructive options from a group of experienced international spine tumor surgeons. Material and Methods An electronic search of the literature was undertaken from January 1990 – December 2013 evaluating specific reconstructive techniques of the spine after primary tumor enbloc resection. Prospective/retrospective trials and case series were included in the final analysis when fusion rates or failure rates were reported. The data available for each reconstructive technique was then combined and construct survivorship was summarized. In addition, a questionnaire was administered to a group of 20 international spine tumor surgeons evaluating specific reconstructive preferences at different regions of the spine based on the number of vertebrae resected and whether post-operative radiation was planned. Results The initial search yielded 381 articles with 31 subsequently included for full text review. Fourteen articles were included in the final analysis. There were 146 patients included for final review. There were 2/9 (22%) patients revised from short to long segment constructs and 3 reports of broken pedicle screws with only one requiring revision in longer constructs. Rates of revision for anterior reconstruction were similar for autogenous strut grafts (10%), cages (7.7%) and allograft strut grafts (8.3%). No surgeons responding to the questionnaire recommended short segment posterior constructs. For anterior reconstruction, cages packed with morcellized allograft and autograft were preferred (75%, p < 0.05) while strut bone grafting was choosen more often at the cervicothoracic junction (65%, p < 0.05) and when more than one vertebrae was resected in the mid thoracic spine (75%, p < 0.05). Few surgeons changed their anterior reconstructive technique (15%) or posterior reconstructive technique (10%) when post-operative radiation was planned. Conclusion The literature and consensus opinion supports posterior reconstruction with at least two vertebral levels of support above and below. For anterior vertebral column reconstruction, structural allograft, autograft and cages packed with morcelized bone have shown similar rates of fusion and failure. Expert opinion, however, suggests that structural autograft or potentially vascularized strut grafts should be used when spanning a defect greater than 2 vertebral bodies especially at the cervicothoracic junction.

Introduction Vertebral artery injury is a rare but serious complication of cervical spine surgery with an overall incidence rate of 1.4% (Rampersaud, 2006). Iatrogenic injury of the vertebral artery can lead to serious complications including lateral medullary (Wallenberg) syndrome, quadriparesis, and mortality. The high rate of vertebral artery anomalies in the general population mandates assessment via advanced imaging modalities in the preoperative period (Schroeder, 2013). The rarity of this complication makes it difficult to set expectations after an injury is encountered. This study utilized a multi-center database to compile outcomes data after vertebral artery injury during a cervical spine procedure. Materials and Methods A multi-center retrospective case series was compiled involving 23 medical institutions. Inclusion criteria included patients who underwent cervical spine surgery between 2005–2011 and who sustained a vertebral artery injury. IRBs were obtained from all institutions and data was sent to a private research organization that collected and collated all of the data. Patients were evaluated on the basis of condition-specific functional status using the Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) score, the Nurick scale, and the 36-Item Short-Form Health Survey (SF-36). Results Vertebral artery injuries were identified in a total of 14 of 16,582 total patients screened (8.4 per 10,000). The mean age of patients with vertebral artery injury was 59 years (+/− 10) with a female predominance (78.6%). Diagnoses of affected patients included 7 with myelopathy, 3 with radiculopathy, 1 with cervical instability, and 2 with metastatic disease. The mean duration of operative time for cases was 4.7 hours (+/− 1.8). Vertebral artery injury was also associated with substantial blood loss (770 mL), although only 3 cases required transfusion. Of the 14 cases, 7 occurred with an anterior only approach, 3 cases with posterior only approach, and 4 during circumferential approach. Average length of hospital stay for these patients was 10 days (+/− 8). Notably, 13 of the 14 (92.86%) cases reportedly resolved without residual deficits. Compared with preoperative baseline NDI, Nurick, and SF-36 physical and mental component scores for these patients, there were no observed changes after surgery ( p = 0.20 Ð 0.94). Conclusion Vertebral artery injuries are potentially catastrophic complications that can be sustained from either anterior or posterior cervical spine approaches. This adverse event is associated with an increase in hospital stay and functional disability measured on NDI score. However, the data from this study suggests that with proper steps to ensure hemostasis, patients recover function at a high rate and do not exhibit residual deficits (13 out of 14). Preoperative imaging studies may provide insight into VA anomalies and anatomic variations and are vital to the preoperative assessment. Furthermore, although surgeons should expect increased blood loss once a vertebral artery injury is encountered, patients do not often require a blood transfusion.

Introduction Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of all cancer patients and is associated with shortened survival and worsened quality of life. This study aims to identify the key survival prognostic factors in MESCC patients who were surgically treated for a single symptomatic lesion. Material and Methods 142 MESCC patients were enrolled in a prospective North American multi-center study and followed postoperatively for 12 months. Using univariate analyses, Kaplan-Meier methods, and log-rank tests the prognostic value of various clinical predictors were assessed. Non-collinear predictors with p < 0.05 in univariate analyses were included in the final Cox proportional hazards model. Results The overall median survival was 7.7 months (range: 3 days – 35.6 months); breast cancer had the longest median survival (12.1 months). Ten patients (7%), whose primary cancer were lung (3), kidney (3), sarcoma (2), prostate (1), and breast (1), died within 30-days postoperatively and 88 had died at 12 months (62%). Univariate analyses yielded eight significant predictors for survival: the growth of primary tumor (Tomita Grade 1 vs Grade 2 and 3), BMI, gender, preoperative SF-36 physical component, EQ-5D, and ODI scores as well as the presence of either visceral or extraspinal bony metastasis. The multiple regression analysis revealed that the Tomita grade (Grade 1 vs Grade 2 and 3; HR: 2.81, p = 0.007), the absence of visceral metastasis (HR: 2.01; p = 0.0044), and higher score on SF-36 physical component (HR: 0.95, p < 0.0001) were independent predictors for longer survival regardless of the selection method used (backward, forward, or stepwise). Conclusion Slow growing tumor (Tomita Grade 1), absence of visceral metastasis, and lower degree of preoperative physical disability, as reflected by a higher score on the SF-36 physical component questionnaire, are good prognostic factors for survival in selected patients who underwent surgical treatment for a focal symptomatic MESCC lesion.