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Imaging Cranial Base Chordoma and Chondrosarcoma

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Chordomas and chondrosarcomas are uncommon primary bone tumors with a predilection for the skull base. On computed tomographic (CT) and magnetic resonance (MR) examinations, they have well-described imaging features that help to distinguish them from each other and from other skull base…

Differential Diagnosis of Clival and Spinal Tumors

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Introduction The differential diagnosis of clival and spinal tumors is vast and includes a variety of neoplastic and nonneoplastic lesions. These lesions may arise primarily from inside the bone and surrounding soft tissue and secondarily as metastasis from distant cancers. Their presenting…

Demographics, Presentation, and Diagnosis

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Introduction Chordomas and chondrosarcomas are rare bone cancers. Their estimated combined annual incidence varies from 0.3 to 1.0 every 100,000 persons ; together, they represent less than 1% of all intracranial tumors and 6% of all primary skull base tumors. Chordomas account…

Molecular Drivers in Chondrosarcoma

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Introduction Chondrosarcoma is a malignant cartilage-forming tumor accounting for 20% of all malignant bone tumors. Only a small percentage of chondrosarcomas is found in the skull or spine (2%–12%). Depending on the subtype, different molecular pathways are involved in development and progression…

Molecular Drivers in Chordoma

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Pathogenesis and Molecular Biology of Chordoma Chordomas are rare primary bone tumors with an annual incidence of less than 0.1 per 100,000 individuals. They develop from the remnants of the primitive notochord and have a predilection for the axial skeleton, most commonly…

Pathology of Chordoma and Chondrosarcoma of the Axial Skeleton

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. The axial skeleton is composed of a variety of tissues, including bone, hyaline cartilage, fibrocartilage, notochord, elastic tissue, tendon, ligament, peripheral and central nervous tissue, fat, hematopoietic elements, smooth muscle, skeletal muscle, blood vessels, and synovium. Neoplasms of the axial skeleton may…

Embryology of the Skull Base and Vertebral Column

© 2018 Elsevier Inc. All rights reserved. Please note that the copyright for the original figures submitted by the contributors is owned by Contributors. Introduction The development of the human skeleton begins soon after conception; the skeleton continues to grow until a peak bone mass is achieved during young adulthood and then remodels throughout adult life. The formation of the skeleton depends on the basic biological…

Development of New Technologies in Spine Surgery

Summary of Key Points Innovation and the subsequent development of new technology is an integral component of modern healthcare delivery. New technology may modify and improve an existing treatment or technique; it may create new treatments and approaches for patients with disorders that previously lacked any viable management options. Few surgical specialties have benefited from innovation and new technology development as much as spine surgery, which,…

Healthcare Reform and Spine Surgery

Summary of Key Points Spinal disorders pose a major burden to our healthcare economy, and are a priority based upon prevalence and impact on health-related quality of life. Payment reform includes: managed care models, accountable care organizations, bundled care payment initiatives, and pay for performance models. Value-based payment systems must keep patient outcomes and patient perspectives primary regarding metrics of performance. Payment reform has a major…

Precision Medicine: Artificial Intelligence Applied to Evaluation and Management of Spinal Disorders

Summary of Key Points Artificial intelligence (AI) and machine learning offer significant promise for improving the state of the art in evidence-based diagnosis and management of spinal disorders AI is the effort to automate intellectual tasks, and encompasses a variety of approaches, including machine learning. Machine learning is a specific approach to AI in which machines learn directly from data. There are a large number of…

Appropriate Use Criteria in Spine Surgery

Summary of Key Points Appropriate use criteria are developed to define which patients certain medical and surgical procedures are appropriate for and when the benefits sufficiently exceed the risks, thus making the procedure worth doing. The RAND Corporation/University of California Los Angeles Appropriateness Method uses extensive literature review and an expert panel to classify indications as appropriate, equivocal, or inappropriate. Appropriateness criteria have been developed for…

Art and Science of Guideline Formation

Summary of Key Points Clinical practice guidelines have become an integral part of the practice of medicine. They are here to stay and will continue to inform clinical practice. Important resources exist to help with the formation of these guidelines and to provide an archive of existing guidelines and those in the process of being made. Clinical practice guidelines need to be reviewed in a timely…

Meaningful Retrospective Analysis

Summary of Key Points Confounders in clinical investigation are systematic errors that cause a tendency toward erroneous results. The two major forms of bias in retrospective studies are selection bias and missing data. Case-control studies are used to identify factors that might lead to a particular outcome by looking retrospectively and comparing cases with a particular outcome to controls without that outcome. These types of studies…

Art of the Clinical Trial

Summary of Key Points The randomized controlled trial (RCT) is the gold standard in evidence-based medicine. Surgical RCTs can be affected by several types of bias, including informational bias, which occurs owing to a lack of blinding, and response bias, which occurs when a significant percentage of patients with a particular outcome do not provide outcomes data. Comparative effectiveness research aims to use modern clinical trial…

Conflicts of Interest in Spine Surgery

Summary of Key Points A conflict of interest is defined as “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).” Spinal surgeon relations with implant manufacturers are especially prone to conflicts of interest because of rapid industry growth, declining reimbursements,…

Spine Registries

Summary of Key Points Registries and databases provide opportunities to capture “real-world” data. Capturing and studying “real world” outcomes of routinely performed spine surgery has a two-fold advantage: It allows us to optimize patient outcomes by identifying drivers of adverse events such as readmissions, reoperations, and complications. It helps optimize cost-effective strategies by allowing care teams and departments to identify drivers of low-value outcomes, such as…

Big Data in Healthcare

Summary of Key Points Medicine is generating approximately a quintillion bytes of data every day, and within those admittedly disorganized, unstructured, or uncurated data streams are transformative insights about patient care and disease treatment. “Big Data” systems, which include advanced software algorithms like artificial intelligence and machine learning, have the potential to unlock those insights, thereby improving the predictive value of medical information, as well as…

Spinal Wound Closure

Summary of Key Points Effective management of spinal wounds require a thorough understanding of the soft tissue anatomy of the back. The basis for avoiding spinal wound complications relies on basic surgical principles, such as a clean, vascularized wound, organized layered closure, and optimization of patient wound healing factors. Vancomycin powder applied during primary closure has been effective in reducing surgical site infection. If a wound…

Vascularized Bone Grafts in Spine Surgery

Summary of Key Points Vascularized bone grafts combine structural properties with biological enhancement through vascularization. Common indications for vascularized bone grafts include: Bone graft greater than 5 cm Strut graft that will be more than 4 cm from the anterior border of the spine and thus more prone to fracture A pseudoarthrosis after a nonvascularized bone graft An area of the spine that will require radiation…

Harvest of Autograft for Spinal Fusion

Summary of Key Points The gold standard for fusion substrates in spine surgery has historically been autogenous bone, particularly that of the iliac crest because of its readily available supply of both cortical and cancellous bone. Iliac crest bone graft (ICBG) offers the most advantage in providing a successful arthrodesis out of any bone grafting option available today; however, it is also associated with the highest…