BACKGROUND CONTEXT:It is currently unknown what absolute change in Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) represents a clinically meaningful change for a patient which causes challenges with the interpretation of the SOSGOQ2.0 total score or domain scores. PURPOSE:The aim of this study was to determine the minimally clinically important difference (MCID) for the SOSGOQ2.0 in patients with spinal metastases. STUDY DESIGN:An international multicenter prospective observational study by the AO Spine Knowledge Forum Tumor. PATIENT SAMPLE:Patients with spinal metastases who were treated with surgery and/or radiotherapy OUTCOME MEASURES: Health related quality of life (HRQOL) was evaluated using the SOSGOQ2.0 at predefined time points METHODS: The MCID values for the SOSGOQ2.0 were determined using both distribution-based as well as anchor-based methods. For the anchor-based method, the posttherapy questions of the SOSGOQ2.0 served as the anchor with response options collapsed into "improvement," "no change" and "deterioration." Spearman correlation coefficients were calculated to identify posttherapy items with a correlation of ≥0.30 with the corresponding domain scores. MCID values from the distribution-based methods were derived using the statistical characteristics of the study population and compared to the anchor-based results. RESULTS:A total of 317 patients had SOSGOQ2.0 data available at baseline and at 12 weeks posttreatment and were included in the final analyses. Anchor-based MCID values for improvement in the physical function, pain, mental health and social function domains were 10.2, 26.0, 14.4 and 17.2 respectively. Compared with the distribution-based approach, anchor-based MCIDs for improvement suggest that the patient-perceived improvement corresponds to a strong level of improvement. CONCLUSIONS:This is the first study to report MCID values for the SOSGOQ2.0 total score and domain scores. The distribution-based MCID estimates will help both clinicians as well as researchers with the interpretation of the effect of treatment for painful spinal metastases on patient reported health related quality of life (HRQOL). TRIAL REGISTRATION:Clinical trials identifier NCT01825161.

BACKGROUND CONTEXT Obesity has been shown in some studies to increase the rates of poor bone healing and adverse outcomes. Bone grafts may influence local biology to improve the environment for bone fusion. P-15L is a composite bone graft containing P-15, a peptide mimicking the cell-binding domain of Type I collagen, and was recently approved by the FDA for use in lumbar interbody fusion. PURPOSE This study presents a subgroup analysis of the obesity higher-risk cohort within a randomized controlled trial (RCT). STUDY DESIGN/SETTING Subgroup analysis from a multicenter, pivotal, prospective, randomized, controlled FDA Investigational Device Exemption trial evaluating P-15L versus autograft in transforaminal lumbar interbody fusion (TLIF). PATIENT SAMPLE A total of 290 patients aged 22–80 years were enrolled at 33 sites and randomized 1:1 to either P-15L or local autograft (control) during single-level TLIF. Block randomization was used to avoid imbalance within centers and risk groups. Obesity was defined as BMI ≥30 kg/m². This analysis focuses on the obesity cohort treated with P-15L (n=63) or control (n=62). OUTCOME MEASURES The primary outcome was Composite Clinical Success (CCS) at 24 months, defined by five criteria: (1) no index-level secondary surgical procedure; (2) achievement of fusion; (3) ≥15-point improvement in Oswestry Disability Index (ODI); (4) no new or worsening persistent neurological deficit; and (5) no serious device-related adverse events (SAEs). METHODS Patients undergoing single-level TLIF with a PEEK cage and supplemental pedicle screw fixation were included. Fusion was assessed at 6, 12, and 24 months by two independent blinded radiologists using thin-slice CT, defined as continuous mature bridging bone from endplate to endplate. CCS required all five criteria to be met. RESULTS In the obesity cohort, CCS was significantly higher for P-15L (52.4%) compared with control (33.9%) (p<0.05). Fusion at 24 months was also higher in the P-15L group (83.3%), representing a 26.8% increase compared with control (56.5%). There were no meaningful differences between groups in index-level secondary surgical procedures, device-related SAEs, ODI improvement, or neurological outcomes. CONCLUSIONS Limited clinical data exist regarding bone graft biomaterials in higher-risk obese patients. In this multicenter RCT subgroup, P-15L demonstrated significantly higher composite clinical success and fusion rates compared with autograft without compromising safety. These findings support P-15L as an effective option for enhancing bone healing in obese patients undergoing lumbar fusion. FDA Device/Drug Status P-15L (P-15 Peptide Enhanced Bone Graft) is approved for this indication.

BACKGROUND:Cervical traumatic spinal cord injury (SCI) is a devastating condition that can result in tetraplegia. Early surgical decompression and rehabilitative efforts in cervical SCI patients has been shown to improve neurological outcomes. In this study, we sought to evaluate the impact of various factors at the time of injury and throughout the rehabilitative period on motor functional independence after 1 and 5 years after injury in patients undergoing cervical spinal cord decompression. METHODS:A longitudinal, retrospective cohort study from the multicenter spinal cord injury Model Systems (SCIMS) database was conducted on patients who presented between 1998 and 2011 with motor Functional Independence Measure (mFIM) scores at rehabilitation admission (RA) and discharge (DC) from inpatient rehabilitation (IPR), year 1, and year 5. Patients who had undergone surgical decompression with neurological levels of injury limited to the cervical region and those with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades of A and B were included. The mFIM score was utilized to calculate changes in mFIM (ΔmFIM) scores over each respective time period. Multivariable logistical regression was performed to identify longitudinal predictors associated with functional independence controlling for demographics, SCI etiology and level, vertebral bony fracture/dislocation, associated injuries, AIS grade, and discharge disposition. RESULTS:A total of 351 patients were included. A majority were 15-29 years old (53.6%) and 80.1% male. Vehicular-related etiologies (49.9%) were most commonly implicated as the mechanism of cervical SCI. Most patients were AIS grade A at the time of RA (66.4%), with an average time from injury to RA of 19 days (IQR 11-32) for all patients. A total of 131 patients required ventilatory support at the time of RA, and of those, only 12 eventually became FI by year 5. Although the number of patients requiring ventilatory support decreased from 131 to 20 by year 5, no additional patients became FI if they required support at the time of DC or year 1. By 1 year, 43 (12.3%) patients achieved functional independence, and an additional 12 (3.42%) achieved functional independence by year 5. Although those with AIS B injuries (aOR = 5.23, P = 0.0014) and AIS improvement (aOR = 5.14, P = 0.0004) had a greater likelihood of FI by year 1, year 1 FI was more strongly predicted by greater ΔmFIM score during a shorter IPR time period (ΔmFIM score during IPR, aOR = 14.2, P < 0.0001). While AIS grade and AIS improvement were no longer predictive of year 5 FI (P > 0.09 for both), the ΔmFIM score during IPR remained as the strongest predictor towards achieving FI by year 5 (aOR = 23.1, P < 0.0001). Furthermore, a stratified analysis of those patients who did not achieve FI at year 1 revealed that the ΔmFIM score during IPR was an even greater predictor of FI at year 5 (aOR = 53.0, P < 0.0001). A similar relationship was observed where stratification of patients by AIS grade showed that AIS A injuries demonstrated a higher likelihood of 5-year FI due to ΔmFIM score during IPR (aOR = 51.3, P = 0.0002 vs. AIS B: aOR = 42.2, P = 0.0009). Similarly, stratification by need for ventilatory support at RA revealed those who did require ventilatory assistance at RA also had a higher likelihood of 5-year FI due to ΔmFIM score during IPR (aOR = 171, P = 0.035). CONCLUSION:In patients who suffered an AIS A/B cervical SCI, IPR contributed to achieving functional independence in up to 5 years after the inciting injury. By year 1, 12.3% of patients achieved functional independence, and from years 1 to 5, an additional 3.42% of patients achieved functional independence. Although AIS B patients and patients with AIS improvement had improved outcomes at year 1, only the ΔmFIM score during IPR predicted eventual FI status by year 5. Due to the increased likelihood attaining functional independence at year 5 in AIS A SCI, carries emphasized importance for patients who do not attain functional independence by year 1. Our study highlights the crucial role of early and aggressive rehabilitation following surgical intervention toward ultimate functional independence in traumatic cervical SCI patients enduring complete loss of motor function.

BACKGROUND:Operating room ergonomics uniquely predispose spine surgeons to chronic musculoskeletal pain. We surveyed the Lumbar Spine Research Society to better characterize the prevalence, surgical challenges, institutional response, and nonoccupational factors of chronic pain among spine surgeons as well as its effects on their careers and well-being. METHODS:A survey of demographic, lifestyle, occupational, and symptomatic information was distributed at the 2024 Lumbar Spine Research Society Annual Meeting. Univariate and multivariate analyses were conducted to assess chronic pain prevalence and severity. Owing to the sample size, a P value of 0.10 was considered statistically significant. RESULTS:Forty surgeons responded; chronic pain affected 82.5%, limited daily activities in 58%, and affected overall fitness in 33%. All reported that ergonomic advancement could improve their practice. Institutions had addressed ergonomic challenges for 5% of respondents and made improvements for 2.5%. In univariate analysis, age correlated with pain prevalence (P = 0.016), while height (P = 0.021), weight (P = 0.050), sleep (P = 0.089), work hours (P = 0.070), and robotic assistance (P = 0.010) were inversely correlated with pain prevalence. Age (P = 0.027), weight (P = 0.0054), and robotic assistance (P = 0.0030) were also inversely correlated with pain severity. Multivariate analysis showed that sleep was inversely correlated with pain (P = 0.062). CONCLUSIONS:Chronic musculoskeletal pain is up to four times more common among spine surgeons than it is among other adults. Sleep and robotic assistance may represent protective factors, but other risk factors and protective factors remain unclear. Ubiquitous symptoms and lack of institutional interventions underscore opportunities to better support spine surgeons and improve career longevity.

Study Design Review of the literature with critical appraisal and clinical recommendations.Objective To highlight contemporary concepts involving adjunctive medical and non-surgical therapies in the management of acute traumatic spinal cord injury (tSCI) that may be integrated into clinical practice.Methods Three recent articles relating to the management of acute tSCI were selected and critically appraised. Clinical practice recommendations were developed and evaluated using the GRADE criteria.Results Article 1: A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management. Conditional recommendation to augment mean arterial blood pressure to at least 75-80 mmHg but not higher than 90-95 mmHg for a duration of 3-7 days to optimize spinal cord perfusion in acute tSCI. Article 2: Spinal Cord Perfusion Pressure Predicts Neurologic Recovery in Acute Spinal Cord Injury. No recommendation can be made at this time in the utilization of SCPP-guided hemodynamic management as an adjunctive strategy in the acute care of tSCI. Article 3: Safety and Efficacy of Riluzole in Acute Spinal Cord Injury Study (RISCIS). No recommendation can currently be made on the routine use of riluzole to patients with acute cervical tSCI.Conclusions The management of tSCI extends beyond the operating room. The development of emerging medical and non-surgical treatments to augment timely and adequate decompression requires critical consideration as new data becomes available. While some topics do not have the scientific backing to be able to make a recommendation at this time, they point towards areas of future study.

Background:Spinal tumors are neoplasms occurring in or around the spinal cord and can be classified based on tissue type and location within the spine. These lesions can lead to spinal cord compression and neurologic deficit. Low- and middle-income countries (LMICs) often face a significant burden of disease due to limited access to healthcare and advanced treatments. We investigate surgical and adjunctive therapies for spinal column tumors in LMICs. Methods:A systematic search was completed to identify articles related to spinal tumors in LMICs. Data were extracted for study parameters and patient outcomes. Country-specific variables were collected for each country. A pooled meta-analysis was completed with this data. Results:Of 99 included articles, 67 provided data on gross total resection (GTR), while 39 articles reported use of adjunctive therapies. Since 1990, there has been an increase in the use of both treatments in LMICs; however, there were significant correlations between the use of adjunctive therapy, life expectancy, and access to healthcare. Conclusion:While treatment and outcomes of spinal column tumors vary within the United States based on socioeconomic factors, including income and gender, this has not been studied on a global scale and in relation to accessibility of specific treatments in LMICs. In this study, we found that specific diagnoses and country income levels were significant drivers of GTR or adjunctive therapy rates. The poor accessibility of these treatments may be overcome with targeted investment, and this should be explored in future research.

Magnetic resonance imaging (MRI) at 7 T (7T) offers higher signal-to-noise ratio and improved spatial resolution compared to lower magnetic field strengths such as 1.5T and 3T, which may improve lesion detection and anatomical visualization for spinal cord pathology. This review summarizes current techniques and achievements in 7T spinal imaging and outlines associated technical barriers and future directions. A scoping review in accordance with PRISMA extension for scoping reviews guidelines was performed utilizing PubMed, Scopus, and Web of Science. Only studies related to 7T MRI of human subjects were included, after removing unrelated studies and those of non-human subjects. Twenty-nine studies were included. Current literature supports 7T’s superior resolution and signal-to-noise ratio in comparison to 1.5T and 3T MRI. These studies reported improved lesion detection and staging in multiple sclerosis (MS), spinal cord injury (SCI), and amyotrophic lateral sclerosis (ALS); however, the implications of results are limited by small sample sizes, technical heterogeneity, and inconsistent outcome measures. Additionally, the use of 7T spinal imaging remains limited by radiofrequency coil design, susceptibility artifacts, physiological noise, lack of FDA-clearance for spinal indications, and an absence of standardized imaging protocols. Future research aims to address these limitations. Spinal cord imaging at 7T is challenging due to technical constraints and higher susceptibility to artifacts as a result of physiological noise (respiration, swallowing, and bulk movement). However, early studies’ results using 7T imaging support improved ability, compared to 3T, to provide enhanced visualization of fine anatomical structures, such as nerve roots, and to improve spinal cord lesion detection.

INTRODUCTION:Low- and middle-income countries experience high pediatric traumatic brain injury rates. A decompressive craniectomy (DC) is a viable option for patients who are unresponsive to medical management. In 2019, the AANS Joint Section for Neurotrauma developed guidelines for pediatric TBI; however, the literature regarding socioeconomic factors that influence the success rate of DC in resource-poor environments remains sparse. Identification of these barriers is important to modify appropriate guidelines for these communities. METHODS:A PRISMA-adherent systematic review of four databases was performed to identify all primary articles investigating outcomes following DC in pediatric patients. Data were extracted for study features and primary outcomes including mortality and postoperative functional status. Socioeconomic epidemiological metrics, including poverty, population density, and health outcomes, were obtained from the United Nations and World Bank. A multivariable meta-regression analysis was performed to evaluate epidemiological factors influencing the pooled mortality and GOS estimates. RESULTS:Data from 39 studies, spanning 17 unique countries were abstracted. The mean age of patients in LMIC undergoing DC was younger, mean 4.74 (sD = 2.76) vs. mean 9.37 (sD = 3.52). Factors correlated with mortality rate included Human Development Index (HDI) (B (SE) = -2.33 (1.02), p = 0.022), population density (0.798 (0.188), p < 0.001), percent of urban population (-0.02 (0.007), p = 0.006), percent of underweight population under 5 years of age (0.028 (0.011), p = 0.010), school enrollment (-0.018 (0.006), p = 0.006), LMIC status (0.83 (0.323), p = 0.010), and the number of hospital beds (-0.12 (0.039), p = 0.002). Post-operative GOS was not associated with any epidemiological covariates. CONCLUSION:Socioeconomic determinants predict the success rate of DC in pediatric traumatic brain injury. Population density and the number of hospital beds having the strongest correlation to mortality rate indicate that low-resource, high-volume communities suffer from worse outcomes post-DC.

Study DesignReview of the literature with critical appraisal and clinical recommendations.ObjectiveTo highlight contemporary concepts relating to surgical care for acute traumatic spinal cord injury (SCI) based on recent evidence that may be integrated into clinical practice.MethodsThree recent articles relating to the surgical management of acute traumatic SCI were selected and critically appraised. Clinical practice recommendations were developed and graded as strong or conditional.ResultsArticle 1: Early vs late surgical decompression for central cord syndrome. Strong recommendation to consider early surgery (<24 hours) as an option in patients with ASIA Impairment Scale (AIS) grade C central cord syndrome. Article 2: Extent of decompression in motor complete SCI. Conditional recommendation to consider laminectomy, with or without anterior surgery, to achieve circumferential decompression of the spinal cord. Article 3: Use of intra-operative ultrasound. Conditional recommendation to use ultrasound intra-operatively to confirm the adequacy of surgical decompression.ConclusionsTimely and adequate decompression of the spinal cord are critical priorities in the management of acute traumatic SCI. The importance of timeliness extends to central cord syndrome. Careful consideration and use of operative techniques (e.g., addition of laminectomy) and adjuncts (e.g., intra-operative ultrasound) help achieve safe and adequate decompression of the spinal cord.

IntroductionTraumatic spinal cord injuries (TSCIs) are associated with high morbidity rates that can affect motor, sensory, and autonomic function. SCIs commonly result from sports, motor vehicle accidents, and other blunt traumas.ObjectiveTo determine risk factors for in-hospital mortality, in-hospital complications, and increased length of stay (LOS) following TSCI.MethodsData from the United States (US) National Trauma Data Bank (NTDB) from 2017 to 2021 was collected and used to assess risk factors for increased in-hospital mortality, complications, and hospital length of stay. Univariable analysis was completed on the 2017-2018 data. Variable importance was calculated, and a logistic regression was performed using the most important variables. Internal and external validation was completed using a testing cohort and 2020-2021 data.ResultsSpinal fusion was associated with decreased mortality but increased complications and LOS. Increased age and injury severity score was associated with increased mortality, complications, and LOS, while the emergency department Glasgow Coma Score was inversely related to all outcomes. Each model had moderate to high prediction ability based on internal area under the curves (AUCs) ranging from 0.757 to 0.899 and external AUCs between 0.744 and 0.884.ConclusionUnderstanding the factors that contribute to poorer outcomes following TSCI can help inform physicians of best treatment practices and patient prognosis. We highlighted five risk factors that correlate with short-term patient outcomes. Future research will further explore how treatment can impact both short - and long-term outcomes.

This study aimed at comparing the costs of spinal fusion surgery between patients with and without diabetes. Following PRISMA guidelines, a systematic search of four databases was conducted. A meta-analysis was performed on comparative studies examining diabetic versus non-diabetic adults undergoing cervical/lumbar fusion in terms of cost. Heterogeneity was assessed using the I2 test. Standardized mean differences (SMD) and odds ratios (OR) with 95

ABSTRACT:Pain is a significant contributor to quality of life for those living with degenerative cervical myelopathy (DCM). The trajectories and factors associated with chronic pain are poorly understood. Patients with DCM were identified from a harmonized data set of the AO Spine Cervical Spondylotic Myelopathy (CSM)-North America, CSM-International, and CSM-Protect studies. Pain scores were prospectively collected using the Neck Disability Index pain intensity (NDI-PI) score preoperatively and at 6-month, 12-month, and 24-month follow-up. Patients were categorized into 3 groups of preoperative pain: severe pain (NDI-PI ≥3), moderate pain (NDI-PI = 2), and minimal pain (NDI-PI ≤1). Latent class trajectory modeling classified patients into distinct trajectories based on their NDI-PI score over 24 months postoperatively. From a total of 952 patients, 32% of patients (n = 305) presented preoperatively with severe pain, 29.1% (n = 277) with moderate pain, and 38.9% (n = 370) with minimal pain. Postoperatively, patients presenting with severe pain followed (1) complete resolution (n = 128, 42.0%), (2) moderate recovery (n = 105, 34.4%), or (3) marginal recovery (n = 72, 23.6%) trajectory. Patients presenting with moderate pain followed the trajectories of (1) pain evolution (n = 22, 7.9%), (2) marginal recovery (n = 104, 37.6%), and (3) complete resolution (n = 151, 54.5%). Patients presenting with minimal pain followed 2 trajectories: (1) no pain evolution (n = 329, 88.9%) and (2) moderate evolution (n = 41, 11.1%). At 24 months, 36.1% (n = 344) of all trajectories ended in chronic pain. Preoperative pain in DCM can be classified into distinct subpopulations with fundamentally differing clinical courses. Surgery is associated with long-term trajectories of pain reduction in painful DCM. However, some patients experience persisting chronic pain.

Objective: Neurosurgeons have long held financial relationships with pharmaceutical and surgical device companies. While industry partnerships drive innovation, there is concern that these collaborations may negatively influence patient care. In response, stakeholders have called for increased monitoring of these relationships. This study aims to provide an up-to-date review of the industry payments to neurosurgeons and how COVID-19 has impacted these payments. Methods: A retrospective study was performed using data from the Center of Medicare and Medicaid Services Open Payments Database (1/1/19-12/31/23). Neurosurgeons were identified using the taxonomy code, 207T00000X. Data collected included the number of payments, purpose, total value, and mean value per year. Results: From 2019 to 2023, 362,270 industry payments were made to 7,846 unique neurosurgeons for a total of $479,072,106. The most common types of payments were for food and beverage (72.7 %), travel and lodging (15.2 %), consulting fees (5.85 %), royalties and licensing (3.02 %), and services other than consulting (1.86 %), while the largest contributors to total payment value were payments for royalties and licensing (57.6 %), consulting fees (14.5 %), acquisitions (12.8 %), services other than consulting (5.00 %), and travel and lodging (3.89 %). Overall, the total amount paid to neurosurgeons decreased during the COVID-19 years (2020-2021) compared to 2019 but rose again in 2022. Conclusion: Neurosurgeons maintain an active financial partnership with industry. Similar to prior reports, payments related to product development comprised the majority of payment value, while payments for food and beverage were the most common. The years of COVID-19, particularly 2020, had a substantial impact on the number, value amount, and subcategory distribution of industry payments made to neurosurgeons. Future investigations of these financial ties on practice, research, and innovation are warranted.

BACKGROUND AND OBJECTIVES: Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW. METHODS: In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS: A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively. CONCLUSION: Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Placement of an external ventricular drain (EVD) involves navigating a catheter into a lateral ventricle of the brain, allowing drainage of cerebrospinal fluid. This can be a life-saving procedure in emergency situations. Ventricular cannulation is classically performed freehand, using landmarks on the skull to align the trajectory. However, this technique is vulnerable to misplacement and can lead to complications. New technologies have emerged to improve EVD placement accuracy and claim to reduce adverse effects. The objective of this report is to examine recent technology developed to improve EVD accuracy. A qualitative review of the literature was completed on publications collected from 6 databases: Pub Med, Medline, Web of Knowledge, Scopus, ClinicalTrials.Gov , and Google Scholar. The google scholar patent search was also used to query all patented devices. Relevant studies presented technology and innovations for EVD placement. The article and patent search returned 15 devices for EVD placement within 4 categories: ultrasound guidance, electromagnetic guidance, computed tomography-based guidance, and mechanical assist devices. The potential benefits of these devices range from real-time feedback for adjustments during insertion to reducing the number of passes and improving placement accuracy. Downsides include the cost of these devices and procedural changes that may increase the overall time of placement. A survey of neurosurgeons and residents found that 51.7% preferred image guidance, 41.6% preferred freehand technique, and 6.7% preferred the Ghajar guide in patients with slit ventricles. Although the freehand technique has been the traditional method for EVD insertion, a number of guidance technologies have been developed to improve placement accuracy. Image-guided procedures have become the preferred method in patients with complicated anatomy. However, changes in procedure time, device availability, and cost have limited the use of these technologies.

Surgery for cervical spondylotic myelopathy (CSM) improves quality of life but surgical approaches might differ by cost. We conducted a post-hoc cost-effectiveness analysis of a prospective randomized trial comparing surgical approaches for CSM. Patients 40 to 85 years of age with CSM were enrolled across 15 sites in North America and randomized (2:3) to either anterior surgery (ACDF) or posterior surgery (LP or PCDF, at surgeon’s discretion). A cost analysis was performed from a societal perspective with a one-year time horizon, including only patients from the United States. Direct costs were estimated using 2022 Medicare reimbursement rates for professional fees and cost-to-charge ratios. Indirect costs were estimated using a human capital approach based on patient surveys. Effectiveness was measured in quality-adjusted life-years (QALYs) using the Euro-Qol-5-Dimensions (EQ-5D) at one year. 153 patients were included as-treated in a three-way cost analysis by surgical approach. Index hospitalization costs were higher after PCDF than ACDF and LP ($32,507 vs. $24,991 vs. $24,574, p<0.0001). 34 patients (22.2%) had complications. Complication costs and lost wages did not differ between groups. One-year total costs were higher after PCDF than ACDF and LP ($49,590 vs. $39,678 vs. $40,716; p=0.0072). For 71 patients with one-year costs and EQ-5D outcomes available, PCDF was associated with lower QALY gains than ACDF (0.687 vs. 0.786, p=0.029) and LP (0.687 vs. 0.791, p=0.062). Among patients enrolled in the CSM-S Trial, LP and ACDF had similar cost-utility. PCDF was less cost-effective, yielding worse outcomes with higher costs, driven primarily by index hospitalization.

OBJECTIVE Surgery is typically indicated for mechanical pain in metastatic spine disease or severe neurological compromise, but how radicular pain responds to oncological treatment is not well described. The primary aim of this study was to describe how radicular pain responds to oncological treatment, while secondary aims included pain outcomes between patients with mechanical and tumoral pain and motor improvement in patients with weakness due to nerve root compression. METHODS Patients treated with surgery and/or radiotherapy for spinal metastases were identified from an international multicenter prospective cohort. The primary outcome was the numeric rating scale (NRS) score for pain at 3 months posttreatment. Motor recovery from radicular compression in patients with myotomic weakness and low-grade epidural compression was also analyzed. RESULTS Of 284 patients, 129 (45%) had radicular pain +/- axial pain and 155 (55%) had axial pain alone. The two groups did not significantly differ in age, comorbidities, tumor characteristics, or treatment. Two hundred two patients (71%) underwent surgery +/- radiotherapy, whereas 82 (29%) had radiotherapy alone. The NRS score of patients with radicular pain improved from 6.7 to 3.4 at 3 months, a statistically significantly higher magnitude than in patients with isolated axial pain (p = 0.021). The NRS score at 3 months was similar for both groups (p = 0.876). Patients with radicular pain experienced a larger improvement with surgery compared with radiotherapy alone (p = 0.007) but had higher pretreatment pain (mean NRS score 7.0 vs 5.6, p = 0.013). Twenty-three patients identified with radicular/myotomic weakness (mean American Spinal Injury Association score 96.3 +/- 3.2) at baseline improved 2.1 +/- 3.8 points at 3 months. CONCLUSIONS The magnitude of pain improvement for patients with radicular pain following surgery and radiotherapy for metastatic spine disease is higher than for patients with axial pain alone. Surgery is associated with a larger improvement in radicular pain than radiotherapy alone. These results will allow clinicians to tailor treatment options for patients with metastatic spine disease.