Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T 2S8. email@example.com
Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
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To compare the clinical characteristics, and short-term outcome of spinal cord infarction and cerebral infarction.
Risk factors, concomitant diseases, neurological deficits on admission, and short-term outcome were registered among 28 patients with spinal cord infarction and 1075 patients with cerebral infarction admitted to the Department of Neurology, Haukeland University Hospital, Bergen, Norway. Multivariate analyses were performed with location of stroke (cord or brain), neurological deficits on admission, and short-term outcome (both Barthel Index [BI] 1 week after symptom onset and discharge home or to other institution) as dependent variables.
Multivariate analysis showed that patients with spinal cord infarction were younger, more often female, and less afflicted by hypertension and cardiac disease than patients with cerebral infarction. Functional score (BI) was lower among patients with spinal cord infarctions 1 week after onset of symptoms (P
In 273 completely paralyzed cord injured patients, the 1-year mortality was 34% in the patients with cervical fractures and 7% in the patients with thoracic and thoracolumbar fractures. Recovery of useful motor function return occurred in 6.7% of the cervical and 11% of the thoracic and thoracolumbar patients; only 1% of the patient population became completely normal. No specific treatment could be singled out as aiding recovery. A case with recovery from complete paralysis after C5--6 fracture-dislocation is presented.
Optimal timing of surgery after a traumatic spinal cord injury (SCI) is one of the most controversial subjects in spine surgery. We assessed the relationship between surgical timing and the occurrence of nonneurologic postoperative complications during acute hospital stay for patients with a traumatic SCI.
A retrospective cohort study was performed in a single institution. Four hundred thirty-one cases of traumatic SCI were reviewed, and postoperative complications were recorded from the medical charts. Patients were compared using two different surgical timing cutoffs (24 hours and 72 hours). Logistic regression analyses were modeled for complication occurrence. The effect of surgical timing on complication rate was adjusted for potential confounding variables such as the level of injury, American Spinal Injury Association (ASIA) grade, Injury Severity Score (ISS), age, sex, Charlson Comorbidity Index, and Surgical Invasiveness Index.
Patients operated on earlier were younger, had less comorbidity, had a higher ISS, and were more likely to have a cervical lesion and a complete injury (ASIA A). A reduction in the global rate of complications as well as in the rate of pneumonias and pressure ulcers were predicted by surgery performed earlier than 72 hours and 24 hours. Increasing age, more severe ASIA grade, and cervical lesion as well as increased Charlson Comorbidity Index, ISS, and SII were also statistically related to the occurrence of complications.
This study showed that a shorter surgical delay after a traumatic SCI decreases the rate of complications during the acute phase hospitalization. We suggest that patients with traumatic SCI should be promptly operated on earlier than 24 hours following the injury to reduce complications while optimizing neurologic recovery. If medical or practical reasons preclude timing less than 24 hours, efforts should still be made to perform surgery earlier than 72 hours following the SCI.
Prognostic study, level III; therapeutic/care management study, level IV.
To determine the involvement of comorbidity to outcomes in a cohort of acute mechanical low back pain patients.
Incident low back pain cases (n=7077) in the acute or subacute phase assessed between January 1, 1999 and December 31, 2001 were included. Patients were categorized into 1 of 2 groups on the basis of their current medical history: (1) those with at least 1 of 7 medical histories considered (Comorbidity Group, n=539), or (2) those with only low back pain (Back Pain Group, n=6538). Main outcome measures were: change in perceived function and visual analog scale (VAS) pain rating from initial assessment to discharge, and total number of treatment days.
There were no baseline statistically significant differences in VAS pain rating, questionnaire score, or symptom duration between groups. Odds ratios (ORs) were adjusted to reflect age and sex differences between groups. Logistic regression analysis revealed no statistically significant difference for change in functional score (OR=1.002) between groups; there were marginal differences in change in VAS pain rating (OR=1.08) and total number of treatment days (OR=1.006). chi analysis revealed no statistically significant differences in medication use, global pain rating, or pain control ability posttreatment, between groups.
Significant ORs were barely greater than 1.00 and were likely the result of the large sample size. The clinical course for comorbid patients, who may seem more complicated at the start of treatment, is just as favorable.
To quantify, in adults with chronic spinal cord injury (SCI): (1) presence of metabolic syndrome versus the general North American population (GP) and (2) 10-year coronary heart disease (CHD) risk using Framingham risk scoring (FRS).
Fasting anthropometric and biochemical data were collected from 75 adults with chronic SCI. Metabolic syndrome was determined using four internationally recognized definitions and FRS using the most recent (2001) algorithm.
Prevalence of metabolic syndrome was up to 5.4 times lower in SCI participants compared to GP, and FRS categorized 3.1% of participants as being at high 10-year CHD risk. However, high-sensitivity C-reactive protein (CRP) values indicated 36.7% of participants as being at high CHD risk.
Current metabolic syndrome definitions and FRS may underestimate true CHD risk in people with SCI. Tools that better identify CHD risk require validation in the SCI population. CRP may be a potential factor to consider in the development of SCI-specific screening tools.
One hundred and one patients with histologically confirmed ependymomas were studied over a 22-year period. Choroid plexus papilloma and sub-ependymoma were not included. About half of the tumors were intracranial, with the majority of these infratentorial. The intraspinal tumors were equally divided between intramedullary and the "cauda" group. The majority of the intracranial tumors occurred in children, while almost all the intraspinal tumors were in adults. The histologic classification consisted of "typical ependymoma" (cellular, papillary and myxopapillary patterns) and "anaplastic ependymoma". The intracranial and intramedullary tumors showed a predominantly cellular pattern, while the myxopapillary type was found only in the "cauda" group. The histology seems to be of limited value in assessing the prognosis in an individual patient with ependymoma. The postoperative prognosis was poor in the intracranial tumors, although radiotherapy increased the survival time without affecting the eventual fatal outcome. The prognosis in the intraspinal group was much better, with three-fourths of the patients living for at least 10 years. No patient with an anaplastic tumor survived for more than 6 years.
In this study we analyzed all acute adult (>15 years) myelitis cases in the province of Uusimaa in Southern Finland during the years 1981-1993. Only cases with acute infectious myelitis were included. Demyelinating diseases, and medullopaties due to degeneration, traumatic, toxic, hereditary, nutritional or metabolic causes were excluded. A total of 45 patients fulfilled the criteria. The mean incidence was 3.5 cases/million inhabitants/year. The mean latency time from the initial infection to the beginning of neurological symptoms was 11 days. Motor paraparesis was found in 62% and tetraparesis in 13%. Sensory symptoms were found in 82% and bowel disturbances were experienced by 71% of patients. Normal cerebrospinal fluid (CSF) leukocytes were seen in 18% of patients, and CSF protein was elevated in 70% of patients. Case fatality was 6.7%. Permanent care in hospital needed by 13% of patients, and after 24 months 88% were ambulatory. Prognosis is quite good in myelitis, and normal CSF leukocytes do not exclude myelitis.