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

OBJECTIVE The purpose of this study was to evaluate the efficacy of spinal implant removal and to determine the possible mechanisms of pain relief. METHODS Fourteen patients with an average of 42 years (from 22 to 67 years) were retrospectively evaluated. All patients had posterior spinal instrumentation and fusion, who later developed recurrent back pain or persistent back pain despite a solid fusion mass. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the Visual Analog Scale (VAS) pain change after implant removal. Clinical outcome using VAS and modified MacNab's criteria was assessed on before implant removal, 1 month after implant removal and at the last clinical follow-up. Radiological analysis of sagittal alignment was also assessed. RESULTS Average follow-up period was 18 months (from 12 to 25 months). There were 4 patients who had persistent back pain at the surgical site and 10 patients who had recurrent back pain. The median time after the first fusion operation and the recurrence of pain was 6.5 months (from 3 to 13 months). All patients except one had palpation pain at operative site. The mean blood loss was less than 100ml and there were no major complications. The mean pain score before screw removal and at final follow up was 6.4 and 2.9, respectively (p<0.005). Thirteen of the 14 patients were graded as excellent and good according to modified MacNab's criteria. Overall 5.9 degrees of sagittal correction loss was observed at final follow up, but was not statistically significant. CONCLUSION For the patients with persistent or recurrent back pain after spinal instrumentation, removal of the spinal implant may be safe and an efficient procedure for carefully selected patients who have palpation pain and are unresponsive to conservative treatment.

/pdf/efficacy-of-spinal-implant-removal-after-thoracolumbar-s7singl0vx.pdf

Efficacy of spinal implant removal after thoracolumbar junction fusion.

Although most of sacral perineural cysts are asymptomatic, some may produce symptoms. Specific radicular pain may be due to distortion, compression, or stretching of nerve root by a space occupying cyst. We report a rare case of S1 radiculopathy caused by sacral perineural cyst accompanying disc herniation. The patient underwent a microscopic discectomy at L5-S1 level. However, the patient's symptoms did not improved. The hypesthesia persisted, as did the right leg pain. Cyst-subarachnoid shunt was set to decompress nerve root and to equalize the cerebrospinal fluid pressure between the cephalad thecal sac and cyst. Immediately after surgery, the patient had no leg pain. After 6 months, the patient still remained free of leg pain.

Sacral Perineural Cyst Accompanying Disc Herniation

Minimally Invasive Lumbar Spinal Decompression: A Comparative Study Between Bilateral Laminotomy and Unilateral Laminotomy for Bilateral Decompression.

Objective
There are technical limitations of multi-level posterior pedicle screw fixation performed by the percutaneous technique. The purpose of this study was to describe the surgical technique and outcome of minimally invasive multi-level posterior lumbar interbody fusion (PLIF) and to determine its efficacy.

Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System : Technical Tips, Surgical Outcomes

Chronic subdural hematoma (SDH) is known to have a good prognosis with relatively simple surgical treatment. Although the potential for recovery from chronic subdural hematoma is very high, unexpected neurologic deterioration may occasionally complicate the postoperative course. Contralateral development of acute subdural hematoma occurring after removal of chronic SDH has been reported recently as a rare but nearly devastating postoperative complication. We report a extremely rare case of a “bilateral” acute SDH occurring after evacuation of chronic SDH with review of the possible mechanism.

Ho Shin

Papers

Efficacy of spinal implant removal after thoracolumbar junction fusion.

Sacral Perineural Cyst Accompanying Disc Herniation

Minimally Invasive Lumbar Spinal Decompression: A Comparative Study Between Bilateral Laminotomy and Unilateral Laminotomy for Bilateral Decompression.

Minimally Invasive Multi-Level Posterior Lumbar Interbody Fusion Using a Percutaneously Inserted Spinal Fixation System : Technical Tips, Surgical Outcomes

Bilateral Acute Subdural Hematoma Following Evacuation of Chronic Subdural Hematoma