Jiong Hao Jonathan Tan

Objective: To examine sociodemographic, clinical, and healthcare-related factors associated with preoperative health-related quality of life (HRQoL) among patients undergoing surgery for degenerative lumbar spine conditions in a multi-ethnic Asian population. Methods: This cross-sectional study used baseline data from the Spine PROM Surgery Registry, including 1194 patients scheduled for surgery within a Singapore healthcare cluster between 2017 and 2022. HRQoL was measured using the EQ-5D-3L, with utility scores crosswalked to the EQ-5D-5L index using the van Hout crosswalk. Hierarchical linear regression assessed factors associated with HRQoL across three blocks: sociodemographic, clinical, and healthcare/lifestyle. Multivariable logistic regression identified factors associated with reporting problems within each EQ-5D dimension. Results: Mean age was 58.1 years (SD 16.1); 51.5% were male. Mean EQ-5D-5L crosswalk index was 0.43 (SD 0.38). Pain/discomfort (93.6%) and usual activities problems (84.3%) were most commonly reported. Lower EQ-5D scores were independently associated with non-outpatient presentation (β = −0.37), non-Chinese ethnicity, primary education or below relative to higher levels, and history of accident or trauma (β = −0.11). Dimension-level analyses showed primary education or below was associated with higher odds of problems across mobility, self-care, usual activities, and anxiety/depression compared with higher education levels, with a clear monotonic gradient. Female sex was associated with higher odds of pain/discomfort and anxiety/depression problems compared with male sex. Non-outpatient presentation was associated with markedly higher odds of self-care problems (OR = 2.98). Conclusions: Patients awaiting lumbar spine surgery appear to have impaired preoperative HRQoL. Although the modest explained variance limits robust risk prediction, preoperative profiles may still help inform clinical discussions and shared decision-making. Non-outpatient presentation may help identify patients who could benefit from enhanced preoperative support, although this requires prospective validation. Differences by ethnicity and education suggest opportunities for culturally tailored counselling. EQ-5D dimension profiles may indicate targets for prehabilitation and provide Singapore-based benchmark data for a lumbar spine surgery cohort for patient-centred care, service benchmarking, and health technology assessment.

Background: Incomplete clinical details on magnetic resonance imaging (MRI) examination requests (MERs) can lead to suboptimal protocol selection. An institutional secure large language model (sLLM) with access to manually retrieved salient data from the electronic medical record (EMR) may improve request completeness and protocol accuracy across multiple MRI subspecialties. Objective: The objective of this study was to compare clinician MERs with sLLM-augmented MERs for information quality and to evaluate the protocoling accuracy of the sLLM versus board-certified radiologists across body, musculoskeletal, and neuroradiology MRI. Methods: This retrospective study included 608 random outpatient MRI examinations performed between September 2023 and July 2024 (body 206, musculoskeletal 203, neuroradiology 199). The cohort comprised 528 patients (mean 51.2 years, SD 19.2; range 4‐93; n=279, 52.8% women, n=249, 47.2% men). MERs without EMR access were excluded. A privately hosted Anthropic Claude 3.5 model (temperature 0) augmented each MER with manually retrieved salient EMR data and, via rule-based parsing, mapped the extracted elements onto predefined institutional criteria to recommend region or coverage and contrast use. Two experienced radiologists established a consensus reference standard. Two board-certified general radiologists (Rad 3 and Rad 4) and the sLLM were compared with this standard. Clinical information quality was graded using the Reason-for-Exam Imaging Reporting and Data System (RI-RADS). Interrater reliability was quantified with Gwet AC1. Paired accuracies were compared with the McNemar test to determine whether there was a statistically significant difference. Results: Interreader agreement for RI-RADS was almost perfect for sLLM-augmented MERs (AC1 0.97, 95% CI 0.94‐0.99) and moderate for clinician MERs (AC1 0.43, 95% CI 0.34‐0.52). Limited or deficient clinical information (RI-RADS C/D) fell to 0% to 0.7% (0/608 to 4/608) with sLLM augmentation vs 4.1% to 20.4% (25/608 to 124/608) for clinician MERs. Overall protocol accuracy was 93.1% (566/608; 95% CI 89.6‐96.6) for the sLLM, 91.4% (556/608; 95% CI 87.6‐95.3) for Rad 3, and 92.1% (560/608; 95% CI 88.4‐95.8) for Rad 4 (sLLM vs Rad 3 P =.23 vs Rad 4 P =.40). Region or coverage accuracy was similar (sLLM: 579/608, 95.2%; Rad 3: 585/608, 96.2%; Rad 4: 573/608, 94.2%; P =.46 and P =.36). Contrast decisions were more accurate using the sLLM at 94.4% (574/608; 95% CI 91.3‐97.5) vs Rad 3 at 92.1% (560/608; 95% CI 88.4‐95.8; P =.027) and were not significantly different to Rad 4 at 92.9% (565/608; 95% CI 89.4‐96.4; P =.16). Subspecialty analyses showed similar patterns, with the sLLM outperforming Rad 4 for musculoskeletal MRI contrast decisions (96.6% vs 91.1%; P =.006) and matching readers elsewhere. Manual review indicated that sLLM improvements arose from EMR details not listed on the MER (infection/inflammation, tumor history, prior surgery). No clinically significant hallucinations were identified in a manual review of discordant cases. Conclusions: Across body, musculoskeletal, and neuroradiology MRI, sLLM-augmented examination requests improved clinical context and enhanced contrast selection while demonstrating accuracy comparable to general radiologists for region or coverage. Integrating sLLMs into routine vetting workflows may reduce manual workload in protocol selection for more efficient, standardized protocoling.

Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) instrumentation has been reported in recent years for metastatic spine tumor surgery (MSTS). The benefits of CFR-PEEK include imaging artifact reduction, which enables more efficient follow-up and adjuvant radiotherapy (RT) planning compared with traditional titanium implants. Despite the increase in CFR-PEEK application in the literature, technical guides or considerations in terms of CFR-PEEK usage in MSTS are currently unavailable. This study aimed to highlight various important technical considerations and potential pitfalls for surgeons when applying CFR-PEEK instrumentation in MSTS. This narrative review was conducted using PubMed, Medical Literature Analysis and Retrieval System Online, The Cochrane Library, and Scopus databases through December 31, 2024. This review included all studies related to CFR-PEEK instrumentation in MSTS. The vast personal experiences of the senior authors with the CFR-PEEK instrumentation circumstantiated the concepts emphasized in this paper. This review included 36 articles and discussed various considerations when planning for CFR-PEEK instrumentation in patients undergoing MSTS. Factors include preoperative construct planning, intraoperative CFR-PEEK system handling, and postoperative considerations such as the requirement for RT planning. This review is the first to highlight various considerations for MSTS surgeons when applying CFR-PEEK instrumentation. This serves as an important guide for surgeons performing MSTS, with the continuous evolution of our treatment capacity in metastatic spinal disease (Level of evidence: IV).

Background: Magnetic resonance imaging (MRI) spine studies frequently reveal extraspinal findings (ESFs) that require further evaluation; yet, the current process of manually reviewing radiology reports and navigating electronic medical records (EMRs) is time-consuming, labor-intensive, and prone to human error. Objective: To address this challenge, we propose using a privacy-preserving large language model (PP-LLM) to automate the identification, classification, and referral assessment of ESFs. Methods: A retrospective analysis of 405 consecutive MRI spine reports from the National University Hospital database, covering February to June 2024, was conducted. Two independent clinicians reviewed the reports and cross-referenced them with EMRs to identify ESFs from the imaging reports. The CT Extracolonic Findings Reporting and Data System (C-RADS) was adapted to determine the clinical significance of ESFs and whether specialty referral was required. The PP-LLM was designed to extract these findings, differentiate between new and preexisting conditions, classify their clinical significance, and generate appropriate referrals. Results: A total of 405 MRI spine reports were initially identified. Five reports were excluded because no relevant EMRs were available, leaving 400 MRI reports from 395 patients for analysis. Among 395 patients (male: 48.1%, n=190; female: 51.9%, n=205; age: mean 54.7, SD 16.7, range 17-89 years), 163 (41.3%) had no ESFs and 232 (58.7%) were reported to have had at least one ESF. A total of 401 ESFs were identified, with the most common findings being renal (n=128, 31.9%), gynecological (n=110, 27.4%), and endocrine-related (n=48, 12%). The PP-LLM correctly detected 99.8% (400/401) of all ESFs and correctly identified all clinically urgent findings (3%, 12/401 of the total, for example, aortic dissection). It misclassified 2% (8/401) of cases into lower C-RADS categories, potentially downgrading clinically significant findings (eg, paranasal sinus mucosal thickening), and 1% (4/401) into higher C-RADS categories, upgrading clinically insignificant findings (eg, dependent changes in the lungs). Additionally, it achieved 98.5% accuracy in distinguishing new from preexisting findings and 96.3% accuracy in assigning the correct specialty referral decision (whether referral is needed, and correct subspecialty referral suggested). The PP-LLM demonstrated almost perfect agreement with the reference standard (Gwet κ=0.959, 95% CI 0.937-0.981), comparable to two human readers (reader 1: κ=0.943; reader 2: κ=0.934), with no statistically significant difference in C-RADS classification accuracy. Notably, it completed the analysis of each report in less than 5 seconds. Conclusions: The PP-LLM demonstrated high accuracy and efficiency in automating the identification and classification of ESFs in MRI spine reports. By integrating this AI-driven automation into clinical workflows, this technology has the potential to enhance efficiency, reduce clinician administrative burden, ensure timely specialist referrals, and improve patient care.

BACKGROUND MRI spine studies frequently reveal extra-spinal findings (ESFs) that require further evaluation, yet the current process of manually reviewing radiology reports and navigating electronic medical records (EMRs) is time-consuming, labour-intensive and prone to human error. OBJECTIVE To address this challenge, we propose using a privacy-preserving large language model (PP-LLM) to automate the identification, classification, and referral assessment of extra-spinal findings (ESFs). METHODS A retrospective analysis of 400 consecutive MRI spine reports from the National University Hospital (NUH) database, covering February to June 2024, was conducted. Two independent clinicians reviewed the reports and cross-referenced them with EMRs to identify ESFs from the imaging reports. The CT Extracolonic Findings Reporting and Data System (C-RADS system), was adapted to determine the clinical significance of ESFs and whether specialty referral was required. The PP-LLM was designed to extract these findings, differentiate between new and pre-existing conditions, classify their clinical significance, and generate appropriate referrals. RESULTS A retrospective analysis of 400 consecutive MRI spine reports from the National University Hospital (NUH) database, covering February to June 2024, was conducted. Two independent clinicians reviewed the reports and cross-referenced them with EMRs to identify ESFs from the imaging reports. The CT Extracolonic Findings Reporting and Data System (C-RADS system), was adapted to determine the clinical significance of ESFs and whether specialty referral was required. The PP-LLM was designed to extract these findings, differentiate between new and pre-existing conditions, classify their clinical significance, and generate appropriate referrals. CONCLUSIONS The PP-LLM demonstrated high accuracy and efficiency in automating the identification and classification of extra-spinal findings in MRI spine reports. By integrating this AI-driven automation into clinical workflows, this technology has the potential to enhance efficiency, reduce clinician administrative burden, ensure timely specialist referrals and improve patient care. CLINICALTRIAL NA

Study Design: Literature review with clinical recommendation. Objective: To provide the readers with a concise curation of the latest literature in recent advances in systemic oncological therapies and their implications for decision-making in patients with metastatic spinal disease. This review aims to enhance spine specialist’s understanding of modern oncological treatments to facilitate optimal timing and planning of local interventions. Methods: The latest literature in the topic of advances in oncology was reviewed by a multidisciplinary group of experts in metastatic spinal disease and clinical recommendations were formulated. The recommendations were dichotomously graded into strong and conditional (weak) based on the integration of scientific methodology and content expert opinion. This opinion considered experience and practical issues such as risks, burdens, costs, patient values, and circumstances. Results: Four high-impact studies were reviewed, demonstrating significant advancements in systemic treatments for metastatic cancers commonly affecting the spine. These studies showed improved survival outcomes and efficacy across breast cancer, colorectal cancer, prostate cancer, and renal cell carcinoma. The findings have important implications for surgical/radiotherapy planning, including considerations for timing of interventions, wound healing, and the potential for extended survival affecting construct durability requirements. Conclusions: Recent advances in systemic oncological treatments have important implications for managing metastatic spinal disease. Understanding these developments is crucial for spine specialists to optimize decision-making through a multidisciplinary approach, particularly regarding timing of local interventions, strategy of the surgical approach and reconstruction.

Study design: Prospective Clinical Study. Objective: Allogeneic blood transfusion (ABT) is the current standard of blood replenishment for metastatic spine tumour surgery (MSTS) despite known complications. Salvaged blood transfusion (SBT) addresses majority of complications related to ABT. We aim to conduct a prospective clinical study to ascertain the long-term clinical outcomes of intraoperative cell salvage (IOCS) in MSTS. Methods: Patients were divided into three groups based on their BT type: no blood transfusion (NBT), ABT and SBT. Primary outcomes assessed were overall survival (OS) and tumour progression (TP), evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12, 24, 36 and 48 months. Results: We included 98 patients [53:45 (M/F)] with mean age of 60 years old. 33 (33.7%) patients received SBT, 39 (39.8%) received ABT and 26 (26.5%) had NBT. All BT groups were comparable for demographics and tumour characteristics ( P = 0.215). Median blood loss was 400 mL and median BT was 620 mL. There were no significant differences between OS of patients who underwent SBT, as compared to ABT or NBT ( P = 0.136). On multivariate analysis, SBT did not show increase in 4-year tumour progression ( P = 0.423). Total blood loss was not associated with tumour progression ( P = 0.260). Conclusions: MSTS patients who had SBT showed comparable OS and TP to ABT and NBT even on long term follow-up. This is the first long term prospective study to report on the clinical outcomes of SBT in comparison with control groups in MSTS and affirms the clinical role of SBT in MSTS.

Background: Metastatic spine tumor surgery (MSTS) is often complex and extensive leading to significant blood loss. Allogeneic blood transfusion (ABT) is the mainstay of blood replenishment but with immune-mediated postoperative complications. Alternative blood management techniques (salvaged blood transfusion [SBT]) allow us to overcome such complications. Despite widespread use of intraoperative cell salvage (IOCS) in oncological and nononcological surgical procedures, surgeons remain reluctant to use IOCS in MSTS. Objective: This study aims to analyze safety of IOCS-leukocyte depletion filter (LDF)–processed blood transfusion for patients undergoing MSTS by assessing clinical outcomes—disease progression: tumor progression and overall survival. This study evaluates whether reinfusion of IOCS-LDF–processed blood reduces ABT rates in patients undergoing MSTS by sorting patients undergoing MSTS who require ABT into patients who consent to receive or not receive SBT. Methods: We aim to recruit a minimum of 90 patients—30 patients for SBT, 30 patients for ABT, and 30 patients with no blood transfusion. SBT and ABT form the 2 experimental arms, whereas no blood transfusion forms the control cohort. Available patient data will be reviewed to determine tumor burden secondary to metastasis and postoperative survival and disease progression, improvement in pain, and neurological and ambulatory status. Data collected will be studied postoperatively at 3, 6, 12, 24, 36, and 48 months or until demise, whichever occurs first. Outcomes of the experimental groups will be compared with those of the control group. Outcomes will be analyzed using 1-way ANOVA and Fisher exact test. The Kaplan-Meier curve and a log-rank test will be used to study overall survival. A multivariate and competing risk analysis will be used to study the association between blood transfusion type and tumor progression. All statistical analyses will be done using Stata Special Edition 14.0 (StataCorp LP). Results: This is the largest clinical study on use of IOCS in MSTS from various primary malignancies to date. It will provide significant clinical evidence regarding the safety and applicability of IOCS in MSTS. It will help reduce use of ABT, improving overall blood management of patients undergoing MSTS. A limitation of this study is that not all patients undergoing MSTS will survive for the follow-up period (4 years), theoretically leading to underreporting of disease progression. Study commenced in 2016 and patient recruitment continued till 2019. As of September 2019, we have collected operative data on 140 patients. However, the 2-year outcomes of about 40.0% (56/140) of patients are in the process of collection. The study is aimed to be published in the years 2023-2024. Conclusions: Results will be disseminated via peer-reviewed publications, paving the way for future studies. International Registered Report Identifier (IRRID): DERR1-10.2196/54609

Study Design: Narrative review. Objective: The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients. Methods: A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included. Results: A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS. Conclusion: Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS. Level of Evidence: Not applicable.