The study group.

BACKGROUND

Chordomas are rare bone tumors arising from remnants of the embryonic notochord.



METHODS

Data for this study were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (1973-2009) to calculate the incidence, relative survival (RS), and standardized mortality ratio (SMR) of patients diagnosed with intracranial and extracranial chordomas and to assess the effects of age and sex on this disease.



RESULTS

The overall incidence of extracranial and intracranial chordomas was 8.4 per 10 million population. The median overall survival of patients with chordoma patients was 7.7 years. The median survival was 7.7 years for male patients and 7.8 years for female patients. Younger patients (aged <40 years) survived longer compared with older patients (10-year RS, 68% vs 43%). The estimated age-standardized 5-year, 10-year, and 20-year RS rates was 72%, 48%, and 31%, respectively. The SMR in the overall cohort was 4.6 (95% confidence interval, 4.22-5.0) or 21.0 (95% confidence interval, 16.6-27.2) in young adult patients and 3.0 (95% confidence interval, 2.6-3.4) in elderly patients.



CONCLUSIONS

The elderly had a more aggressive form of this disease; and, other than the incidence, sex did not influence outcome in this disease. The study of chordomas presents a good case for the contribution that the SMR can have on measuring the impact of a disease on a population of patients. Although the younger population has better survival rates, the impact (SMR) in the younger age groups is much higher than in older populations. Cancer 2013;119:2029–2037. © 2013 American Cancer Society.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.28032

Incidence and relative survival of chordomas: the standardized mortality ratio and the impact of chordomas on a population.

Vertebral compression fracture (VCF) is an important cause of severe debilitating back pain, adversely affecting quality of life, physical function, psychosocial performance, mental health and survival. Different vertebral augmentation procedures (VAPs) are used in order to consolidate the VCFs, relief pain,and whenever posible achieve vertebral body height restoration. In the present review we give the indications, contraindications, safety profile and outcomes of the existing percutaneous VAPs.

CIRSE Guidelines on Percutaneous Vertebral Augmentation

Background
Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear.

Objectives
To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates.

Search methods
Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews.

Selection criteria
This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis.

Data collection and analysis
Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence.

Main results
We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'.

Authors' conclusions
The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.

/pdf/surgical-options-for-lumbar-spinal-stenosis-173dzbyrol.pdf

Surgical options for lumbar spinal stenosis

To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or to avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis. A comprehensive electronic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform was conducted for relevant literature up to June 2014. A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Three different techniques that avoid removal of posterior midline structures are compared to conventional laminectomy; unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy. Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in patients that underwent bilateral laminotomy compared with conventional laminectomy. Unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low. The difference in severity of postoperative low back pain following bilateral laminotomy and split-spinous process laminotomy was significantly less, but was too small to be clinically important. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression. The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies.

/pdf/effectiveness-of-posterior-decompression-techniques-compared-x9pee4xgt3.pdf

Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis

Low back pain is common during pregnancy. However, the prevalence of symtomatic lumbar disc herniation is rare, and cauda equina syndrome due to disc herniation during pregnancy is even rarer. We report a rare case of lumbar disc herniation causing cauda equina syndrome during third trimester of pregnancy which successfully treated by endoscopic discectomy. This case shows that endoscopic discectomy can be the treatment option for the lumbar disc herniation during pregnancy.

/pdf/endoscopic-discectomy-for-the-cauda-equina-syndrome-during-4poncpijsr.pdf

Endoscopic discectomy for the cauda equina syndrome during third trimester of pregnancy.

Ewing's sarcoma usually arises from skeletal bone, but rarely may have an extraskeletal origin. However, Ewing's sarcoma that originates around the spinal column, especially, the intradural extramedullary type is extremely rare. We report a rare case of primary intraspinal extraskeletal Ewing's sarcoma.

Primary Intradural Extraosseous Ewing's Sarcoma.

OBJECTIVE Transpedicular instrumentation of the osteoporotic spine is a challenge for the spine surgeon due to the probability of screw loosening and the potential possibility of nonunion. The purpose of this study was to evaluate the clinical efficacy of bone cement augmented screw fixation in patients with severe osteoporosis. METHODS Between February 2004 and August 2007, 250 patients with severe osteoporosis (T-score on BMD < -3.0) that had screw fixation were included in this study. The patients were divided into two groups (Group I: 157 patients that underwent bone cement augmented screw fixation that had a variety of spine spinal diseases including fractures, and Group II: 93 patients with severe osteoporosis that had screw fixation without bone cement augmentation). The imaging and clinical features were analyzed, including bone cement augmented levels, fusion rate and related complications. The visual analog scale (VAS), Oswestry disability questionnaire (ODI) and modified MacNab's criteria were used for the assessment of pain and functional capacity. RESULTS In both groups, a significant improvement in the VAS and ODI was achieved. 146 out of 157 patients (93%) in Group I and 83 out of 93 patients (90%) in Group II were graded as an excellent or good result according to the modified MacNab's criteria. None of the patients experienced serious complications. However, there were two cases with neurological deterioration as a result of bone cement extravasation in Group I. For Group II, there were five cases of screw loosening that required re-operation for bone cement augmentation. CONCLUSION Whether bone cement augmentation was performed or not, it was possible to achieve satisfactory results in patients with severe osteoporosis. However, if used carefully, bone cement augmented transpedicular screwing can reduce screw loosening and pullout in patients with severe osteoporosis.

/pdf/clinical-efficacy-of-bone-cement-augmented-screw-fixation-2mku11i1h4.pdf

Clinical efficacy of bone cement augmented screw fixation for the severe osteoporotic spine.

Objective
Bone cement augmentation procedures such as percutaneous vertebroplasty and balloon kyphoplasty have been shown to be effective treatment for acute or subacute osteoporotic vertebral compression fractures. The purpose of this study was to determine the efficacy of bone cement augmentation procedures for long standing osteoporotic vertebral compression fracture with late vertebral collapse and persistent back pain.

The Role of Bone Cement Augmentation in the Treatment of Chronic Symptomatic Osteoporotic Compression Fracture

Background Bertolotti's syndrome is a spinal disorder characterized by abnormal enlargement of the transverse process of the most caudal lumbar vertebra. The L5 transverse process may be enlarged either unilaterally or bilaterally and may articulate or fuse with the sacrum or ilium. Pseudoarticulation between the transverse process of the L5 and the alar of the sacrum can cause buttock pain and leg pain. In addition, the L4 exiting nerve root could be compressed by an enlarged L5 transverse process. The authors could have obtained satisfactory results from the selected cases of Bertolotti's syndrome by applying a selective transverse processectomy of the L5. Objective The objective of this study is to determine the effectiveness of L5 transverse processectomy for symptomatic Bertolotti's syndrome. Study design A retrospective study. Methods A total of 256 patients with Bertolotti's syndrome who had severe buttock pain and unilateral or bilateral radiating leg pain were selected. The correct diagnosis was made based on imaging studies which included computed tomography (CT), plain x-rays, and magnetic resonance imaging (MRI). The final diagnosis was made by confirming pain relief from anesthetic block. A total of 87 patients were classified into 2 groups: group A included 50 patients whose pain was relieved by block into the pseudoarticulation and group B included 37 patients whose pain was relieved by block into the L4 exiting nerve root. A total of 61 cases (group A: 39 cases, group B: 22 cases) were selected as pure L5 transverse processectomy. Outcome measures The primary outcome measures were reduction in pain scores and improvement in quality of life. Results Among 61 patients, there were 19 men and 42 women. The mean age of the patients was 53.2 ± 12 years (group A: 57.8 ± 14 years [16 - 86 years], group B: 53.4 ± 14 years [27 - 77 years]). The mean follow-up period was 6.5 months. The patients' mean visual analog scale (VAS) prior to surgery was 7.54 ± 0.81 (group A: 7.59 ± 0.93, group B: 7.50 ± 0.86), and the mean postoperative VAS was 2.86 ± 1.67 (group A: 3.82 ± 1.59, group B: 2.05 ± 1.00). According to Macnab's criteria, 12 patients showed excellent results (group A: 3, group B: 9), 41 patients showed good results (group A: 11, group B: 30), 6 patients showed fair results (group A: 5, group B: 1), and 2 patients showed poor results (group A: 2, group B: 0). Thus, satisfactory results were achieved in 86.89% of the cases. Conclusion In patients with Bertolotti's syndrome, pseudoarticulation as well as L4 nerve root compression can be the source of buttock pain and lower extremity pain. Bisectional cutting of the L5 transverse process and decompression of the L4 nerve root could be an optimal treatment for Bertolotti's syndrome, and it may be easily approached by the paraspinal approach. Limitations This is a retrospective study and only offers one-year follow-up data for patients with Bertolotti's syndrome who have undergone L5 transverse process resection.Key words: Bertolotti's syndrome, pseudoarticulation, L5 transverse processectomy, paraspinal approach.

Ho Shin

Papers

Endoscopic discectomy for the cauda equina syndrome during third trimester of pregnancy.

Primary Intradural Extraosseous Ewing's Sarcoma.

Clinical efficacy of bone cement augmented screw fixation for the severe osteoporotic spine.

The Role of Bone Cement Augmentation in the Treatment of Chronic Symptomatic Osteoporotic Compression Fracture

Decompressive L5 Transverse Processectomy for Bertolotti's Syndrome: A Preliminary Study.