Neil Rainer Malhotra

Introduction: Preoperative opioid use is highly prevalent among spine surgery patients and has been associated with adverse postoperative outcomes in degenerative and adult spinal deformity populations. However, the perioperative significance of opioid burden in spine oncology patients remains poorly characterized. Methods: We retrospectively reviewed 290 spinal tumor patients with documented preoperative opioid exposure. Opioid burden was quantified using morphine equivalent daily dose (MEDD) and cumulative morphine equivalent dose (MED), analyzed as both continuous and dichotomized variables. Associations with discharge disposition, hospital length of stay (LOS), and 30- and 90-day emergency department (ED) visits and readmissions were evaluated using multivariable regression, with coarsened exact matching (CEM) performed as a sensitivity analysis. Results: Following multivariable adjustment, higher continuous MEDD (OR 1.0029, 95% CI 1.0006–1.0055, p = 0.019), continuous MED (OR 1.0934 per 1,000 mg, 95% CI 1.0117–1.1896, p = 0.030), and MEDD above the cohort median (OR 1.6891, 95% CI 1.0145–2.8317, p = 0.045) were associated with increased odds of non-home discharge. However, these associations did not remain statistically significant following false discovery rate correction. No significant associations were identified with LOS, ED visits, or readmissions within 30 or 90 days. Following CEM, 42 MEDD pairs and 40 MED pairs were retained. Matched analyses yielded imprecise estimates with wide confidence intervals, limiting further interpretation. Conclusions: Higher preoperative opioid burden demonstrated nominal associations with non-home discharge following spine tumor surgery, although these findings did not remain significant after correction for multiple comparisons. These exploratory findings suggest that discharge disposition may warrant further investigation as an outcome associated with preoperative opioid burden.

Study Design: Retrospective cohort study. Objectives: As cancer survival improves, metastatic spinal cancer has become increasingly common worldwide. Given the high resource demands of spinal oncology care, tools to optimize perioperative planning are essential. The objective of the study was to assess the effectiveness of the Risk Assessment and Prediction Tool (RAPT) in predicting post-operative needs in patients undergoing surgery for spinal tumors. Methods: Consecutive patients (n = 384) undergoing spinal oncology surgery were enrolled and prospectively assessed with RAPT. Coarsened exact matching (CEM) was used to retrospectively isolate risk factors associated with outcomes. Enrolled patients with a low RAPT score (≤9, n = 44) were exact matched against high-scoring patients (10-12, n = 44). The primary outcome of interest was post-acute care disposition; secondary outcomes were 30- and 90- day ED visits, readmissions, and reoperations. McNemar’s test was utilized for matched comparisons. Results: A low RAPT score was significantly associated with non-home discharge (OR = 4.33 [1.23, 15.20], P = 0.02) and 30-day readmission (OR = 3.66 [1.02, 13.14], 0.03). Among low-scoring patients, 31.8% required post-acute care (while only 11.3% of high-scoring patients required post-acute care). A low RAPT score was not associated with ER visits, reoperation, or mortality. Isolation of the RAPT walk score alone significantly predicted non-home discharge (OR = 2.8 [1.01, 7.78], P = 0.04). Conclusions: When applied prospectively before spinal cancer surgery, the RAPT tool and its subcomponents effectively predict post-acute care needs. Pre-operative prediction of non-home discharge may help guide in-hospital resource allocation and post-acute care of spinal oncology patients.

BACKGROUND AND OBJECTIVES: The purpose of the present work was to review our series of patients with far lateral disk herniations treated by the intertransverse approach. METHODS: Patients undergoing intertransverse approach to treat far-lateral disk herniation by a single surgeon over a 10-year period were identified through the electronic medical record. Additional variables regarding the intraoperative and postoperative course were also collected. Response to treatment was assessed using Odom criteria at the patient's postoperative follow-up. RESULTS: Sixty patients met inclusion criteria. The most frequently treated levels were L3-4 and L4-5 (41.7% and 36.7%, respectively), and 11.7% at L5-S1. The mean age was 56.8 years (SD = 12.6y). Isolated radicular pain was the most common presenting symptom (66%). Two-thirds of patients had mild systemic disease as determined by the American Society of Anesthesiologists score (II). Estimated blood loss ranged from <50 to 600 mL, with a median of 50 mL (IQR 30-120 mL). The mean length of stay was 48h (SD = 46 hours), with 35% of patients (22) undergoing outpatient surgery. The median length of latest postoperative follow-up was 78 days (IQR 34-19 days). Per Odom criteria, most patients had good-to-excellent improvement of preoperative symptoms (80%, N = 48). 8.3% of patients required revision surgery with fusion (N = 5). CONCLUSION: Most patients had good-to-excellent improvement of preoperative symptoms. The paucity of revision procedures in this cohort suggests that the intertransverse approach is durable as it enables direct decompression of the nerve root without destabilizing the motion segment. Further studies are required to compare the efficacy of the intertransverse approach with other approaches.

Background: Subpopulation underrepresentation in clinical trials contributes to biases in clinical data and systemic healthcare inequities. We aim to evaluate reporting and representation, as well as the effect of geography and socioeconomic trends, in spinal oncology trials. Methods: Data were collected from completed spinal oncology trials registered on ClinicalTrials.gov from 2000 to 2023. A total of 42 trials with 5679 participants were included. The demographics of participants were compared with national spinal tumor incidence data and demographic data from patients undergoing spinal oncology surgery at a quaternary care center. Results: Only 50% of clinical trials reported race and 28.6% reported the ethnicity of participants, with privately funded trials less likely to report ethnicity (25% vs. 66.7%, P = .02574). When compared with their respective national incidences, Black (4.6% vs. 11.3%, P < .00001), American Indian or Alaska Native (0.2% vs. 0.6%, P = .00084), and Hispanic (4.7% vs 11.4%, P < .00001) patients were significantly underrepresented in trials. Black (4.6% vs. 18.9%, P < .00001) and female (44.5% vs. 48.9%, P = .00438) patients were also underrepresented when compared with the population of patients undergoing spinal oncology surgery. Trials post-2020 had increases in representation of several minority groups compared to pre-2020 trials. Trial sites were mostly located in metropolitan areas, with gaps in the Mountain region and parts of the Southern U.S. Conclusions: There has been progress in diversifying spinal oncology trials, but there are still large racial, ethnic, and geographic disparities in the composition of clinical trial patients. Major reporting lapses hinder understanding the gaps in equitable enrollment.

Introduction: Intervertebral disc degeneration is strongly implicated as a cause of low back pain. Although the precise pathophysiological mechanisms remain elusive, perturbations in nutrition that adversely impact the cellular microenvironment of the central nucleus pulposus (NP) may be contributing factors. A comprehensive understanding of this microenvironment, including changes in nutrient availability as a function of degeneration, is critical for the development of effective cell‐based treatments. The goal of this study was to adapt brain tissue oxygen probes and microdialysis catheters for in situ determination of relative NP oxygen, glucose, and lactate levels in a preclinical goat model of disc degeneration.Methods: Following ex vivo technical refinement in bovine caudal discs, baseline metabolite measurements were performed in vivo in the lumbar discs of 3 large frame goats. Degeneration was then induced via injection of chondroitinase ABC (ChABC) into the NP, and measurements were repeated after 12 weeks. Degeneration severity was graded using magnetic resonance imaging (MRI) and histology, and vertebral endplate porosity was assessed using microcomputed tomography.Results: Oxygen and lactate levels in goat NPs were significantly higher in degenerate compared to healthy discs, while glucose levels were not significantly different. ChABC‐injected discs exhibited higher vertebral endplate porosity, worse histological and MRI grades, and a spectrum of cartilage endplate damage compared to healthy discs. There were significant positive correlations between MRI grade and both NP oxygen and lactate levels.Discussion: We successfully adapted techniques including surgical placement, equilibration time, flow rate, and detection method for in situ measurement of oxygen, glucose, and lactate in a goat model of disc degeneration. Interestingly, while increased lactate with degeneration was expected, increased oxygen levels were unexpected. Our findings may, in part, be explained by associated alterations in disc and endplate structure, and motivate future studies to comprehensively establish the underlying mechanisms in this model.