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STUDY DESIGN: Retrospective cohort study. PURPOSE: To study the incidence, onset, underlying mechanism, clinical course, and factors leading to asymptomatic construct failure (AsCF) after metastatic spinal tumor surgery (MSTS). OVERVIEW OF LITERATURE: The reported incidence rates for implant and/or construct failure after MSTS are low (1.9%-16%) and based on clinical presentations and revisions required for symptomatic failures (SFs). AsCF after MSTS has not been reported. METHODS: We conducted a retrospective analysis of 288 patients (246 for final analysis) who underwent MSTS between 2005-2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological AsCF were defined as presentation before and after 3 months, respectively. We analyzed patients with AsCF for risk factors and survival duration by performing competing risk regression analyses where AsCF was the event of interest, with SF and death as competing events. RESULTS: We observed AsCF in 41/246 patients (16.7%). The mean time to onset of AsCF after MSTS was 2 months (range, 1-9 months). Median survival of patients with AsCF was 20 and 41 months for early and late failures, respectively. Early AsCF accounted for 80.5% of cases, while late AsCF accounted for 19.5%. The commonest radiologically detectable AsCF mechanism was angular deformity (increase in kyphus) in 29 patients. Increasing age (p<0.02) and primary breast (13/41, 31.7%) (p<0.01) tumors were associated with higher AsCF rates. There was a non-significant trend towards AsCF in patients with a spinal instability neoplastic score ≥7, instrumentation across junctional regions, and construct lengths of 6-9 levels. None of the patients with AsCF underwent revision surgery. CONCLUSIONS: AsCF after MSTS is a distinct entity. Most patients with early AsCF did not require intervention. Patients who survived and maintained ambulation for longer periods had late failure. Increasing age and tumors with a better prognosis have a higher likelihood of developing AsCF. AsCF is not necessarily an indication for aggressive/urgent intervention.

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STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study was to develop a surgical invasiveness index for metastatic spine tumor surgery (MSTS) that can serve as a standardized tool in predicting intraoperative blood loss and surgical duration; for the purpose of ascertaining resource requirements and aiding in patient education. SUMMARY OF BACKGROUND DATA: Magnitude of surgery is important in the metastatic spine disease (MSD) population since these patients have a continuing postoperative oncological process; a consideration that must be taken into account to maintain or improve quality of life. Surgical invasiveness indices have been established for general spine surgery, adult deformity, and cervical deformity, but not yet for spinal metastasis. METHODS: Demographic, oncological, and procedural data were collected from consecutive patients that underwent MSTS. Binary logistic regression, using median values for surgical duration and intraoperative estimated blood loss (EBL), was used to determine statistical significance of variables to be included in the "spinal metastasis invasiveness index" (SMII). The corresponding weightage of each of these variables was agreed upon by experienced spine surgeons. Multivariable regression analysis was used to predict operative time and EBL while controlling for demographical, procedural, and oncological characteristics. RESULTS: Two hundred and sixty-one MSD patients were included with a mean age of 59.7-years and near equal sex distribution. The SMII strongly predicted extended surgical duration (R2 = 0.28, P < 0.001) and high intraoperative blood loss (R2 = 0.18, P < 0.001). When compared to a previously established surgical invasiveness index, the SMII accounted for more variability in the outcomes. For every unit increase in score, there was a 42-mL increase in mean blood loss (P < 0.001) and 5-minute increase in mean operative time (P < 0.001). CONCLUSION: Long surgical duration and high blood loss were strongly predicted by the newly developed SMII. The use of the SMII may aid in preoperative risk assessment with the goal of improving patient outcomes and quality of life.Level of Evidence: 4.

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A large variety of vertebral tumours undergoes transarterial embolisation (TAE) prior to surgery. However, the subsequent intra-operative blood loss is unpredictable. This retrospective analysis, aims to determine the impact of various factors that may potentially influence the estimated intra-operative blood loss (EBL) in these patients. The study included 56 consecutive patients with spinal tumours who underwent pre-operative TAE. Demographic information, treatment history, tumour type, MRI characteristics, angiographic appearance, embolisation technique and surgical invasiveness were correlated with EBL using univariate and multivariate analysis. Mean EBL was 1317 mls. On univariate analysis, haematological/primary tumours, MRI hypervascularity and selective embolisation were significantly (P < 0.05) associated with increased EBL. A total angiographic devascularisation and embolisation of additional segments above and/or below the involved level were significantly associated with decreased EBL. There was no significant association with hypervascular angiographic appearance or surgical invasiveness. MRI and angiographic hypervascularity were not entirely concordant, especially for the category of moderately vascularised metastases. After multivariate analysis, MRI hypervascularity (1434 vs. 929 mls, P = 0.018) and embolisation of additional segments (1082 vs. 1607 mls, P = 0.003) remained significantly correlated with EBL. In conclusion, during pre-operative TAE of spinal tumours, routine angiographic interrogation of additional levels above and below the involved segment should be made, with a low threshold for embolising them, if safely performable. Compared to angiographic gold standard, MRI hypervascularity is probably a better predictor of EBL.

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BACKGROUND: Almost 30% of young athletic patients sustain a second anterior cruciate ligament (ACL) injury within 24months of their ACL reconstruction and returning to pivoting sports. Most patients with high athletic demand and significant anteroposterior instability often require ACL revision surgery to restore their pre-injury activity levels. CASE REPORT: A 24-year old gentleman ruptured his hamstring tendon autograft during a twisting injury seven months after his ACL reconstruction. Eight months post-injury, it was observed that spontaneous healing of his graft had occurred. This was confirmed with clinical examination and radiological imaging. CONCLUSION: Hamstring tendon autografts may demonstrate some self-reparative potential. This could be due to the higher response of extra-articular ligaments and tendons in response to growth factors observed in some studies. Limitations in diagnostic magnetic resonance imaging could also lead to over-interpretation of a partially torn graft.

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We conducted a retrospective review of 221 patients, who underwent spinal oncologic surgery at a tertiary university hospital between 2005 and 2014; in order to identify and validate factors that influence the impact of preoperative embolization of spinal tumours on outcome measures of blood loss and transfusion requirements in spinal oncologic surgery. We also focused on primary tumour type and type of spinal surgery performed. Patients' electronic and physical records were reviewed to provide demographic data, tumour characteristics, embolization techniques and surgical procedure details. These data were analysed against recorded outcome measures of blood loss (absolute volume and haemoglobin reduction) and transfusion requirements. Forty eight patients who received preoperative embolization were compared against 173 patients who did not. There was a tendency towards reduced blood loss and transfusion requirements in embolized spinal metastases from HCC and thyroid; as well as primary spine tumours, though the differences were not significant. Total embolization of arterial supply to spinal tumours resulted in significantly less blood loss as compared to partial or subtotal embolization. In addition, median blood loss was lower in patients receiving a more proximal embolization and in patients who underwent surgery between 13 and 24h post-embolization despite the insignificant difference. To conclude, preoperative spinal tumour embolization is likely to be effective in reducing blood loss if a total embolization is performed 13-24h prior to the surgery. Similarly, the impact of embolization is likely to be more profound in metastases from HCC, thyroid and primary spine tumours.

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STUDY DESIGN: A prospective observational study. PURPOSE: To evaluate the role of nucleoplasty in the management of discogenic axial back pain; to determine the influence of concordant pain during provocative discography, annular tear and loss of disc height on the outcome of nucleoplasty. OVERVIEW OF LITERATURE: The role of nucleoplasty in the management of radicular leg pain due to disc herniation is known. However, the data regarding its role in the management of discogenic axial back pain is scarce. METHODS: A prospective evaluation of 30 patients with discogenic axial back pain undergoing nucleoplasty was performed. Pain, functional disability and quality of life were assessed using the 100 mm visual analogue scale (VAS), Oswestry Disability Index (ODI) and Short Form-36 (SF-36), respectively. RESULTS: The mean reduction in VAS was 31.03 and 29.03; mean reduction in ODI was 24.53 and 20.60; and mean increment in SF-36 was 13.58 and 12.30, at 6 months and at 12 months, respectively. The differences were statistically significant (p <0.05). Concordant pain during provocative discography, annular tear and loss of disc height did not affect a clinically significant improvement in any of the three outcomes (p =0.882, 0.213, and 0.170; respectively). CONCLUSIONS: Nucleoplasty produced statistically significant improvements in pain, functional disability and quality of life in patients with discogenic low back pain at 6 months and at 12 months. Concordant pain during provocative discography, annular tear and loss of disc height did not influence any of the outcomes after nucleoplasty in patients with discogenic axial back pain.