The clinical and oncological data of all the patients and divided by group.
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"50627",title:"Minimally Invasive Surgery for Treatment of Patients with Advanced Cancer and Thoraco-lumbar Spine Metastases",doi:"10.5772/63244",slug:"minimally-invasive-surgery-for-treatment-of-patients-with-advanced-cancer-and-thoraco-lumbar-spine-m",body:'\n
Spinal cord involvement due to vertebral metastases is a frequent complication in cancer patients and metastatic lesions of spine can significantly condition their quality of life, potentially producing untreatable pain, vertebral fractures, or even neurological deficit due to spinal cord or radicular involvement [1, 2]. Spinal metastases are likely to increase their incidence because patients with cancer today can live longer, due to early detection, as well as to improvements in cancer treatment and care [3]. These lesions should be considered and treated both medically or surgically to prevent undesired sequelae, and to preserve or, whenever possible, improve the quality of their residual life [4, 5].
\nThe spine is the third most common site for cancer cells to metastasize, following the lungs and the liver. Almost 70% of cancer patients are expected to have spinal metastasis. In case of symptomatic lesions, the majority (60–70%) are found in the thoracic region, while of the remainder, 20% are found in the lumbar region, and 10% are found in the cervical spine. More than 50% of patients with spinal metastasis have more than one level involved [6, 7].
\nSurgery of spinal metastases cannot be curative, but only palliative, aimed to preserve or, whenever possible, improve quality of life for patients with short- or mid-term life expectancy. In such cases, surgery is indicated for the stabilization of involved segments, for spinal cord or root decompression, and for tissue diagnosis.
\nIn the optic of reducing post-operative morbidity and accelerate the post-operative recovery, minimally invasive spine surgery (MISS) may represent the best option to achieve equivalent or superior outcomes to those of traditional open spine surgery, and to reduce the impact of surgery on critical patients with poor general and neurological conditions with short- or mid-term life expectancy.
\nThe evaluation of clinical general and neurological conditions of patients with advanced cancer and spinal metastases is performed with the Karnowsky performance scale (KPS) and the American Spinal Injury Association (ASIA) scores. Total spine MRI and total body CT scan is mandatory in order to update the stadium of the disease and to planning the most correct treatment.
\nApproximately 90% of cancer patients with spinal metastases have bone and/or back pain, followed by radicular pain. Half of these patients have sensory and motor dysfunction, and more than half have bowel and bladder dysfunction. Five to 10% of cancer patients present with cord compression as their initial symptom; among these, 50% are non-ambulatory at diagnosis, and 15% are paraplegic [8].
\nThe initial functional neurological score, evaluated with ASIA score, is the most important prognostic factor for the neurological recovery of patients undergoing surgery. Surgery, in the majority of spinal metastasis cases, does not have a curative aim, but only palliative, to assure stability, pain control, and maintenance of neurologic integrity [3]. Surgery is also important to confirm the primary diagnosis, to debulk or remove the tumor mass for a more effective adjuvant therapy, and permit a patient’s mobilization.
\nThe main indications for surgery in case of spinal metastases are the progressive neurologic deficit before, during, or after chemo- and radiotherapy, the intractable pain unresponsive to conservative treatment, the need for histological diagnosis, the treatment of radio-resistant tumor histology (e.g., RCC, melanoma), and to restore the spinal stability.
\nNumerous grading systems has been proposed, like the modified Bauer Scoring System (mBS), in order to give an indication to a conservative, palliative or more aggressive surgical treatment to a metastatic spine disease. The modified Bauer classification results equal or inferior then 3 points in case of patients with short- or mid-term life expectancy (Figure 1).
\nModified Bauer Scoring System and the prognostic score.
To improve outcomes for patients with metastatic spine disease, many aggressive surgical strategies have been proposed. Nevertheless, an aggressive strategy is frequently associated with high morbidity and complication rates, and is not generally indicated in patients with poor general conditions and a limited life expectancy [9, 10].
\nThese patients, in fact, often suffer from co-morbidities, malnourishment, diminished immunity, considerable pain, and they cannot face major surgery. Thus extensive surgical procedures or prolonged hospital stays are neither acceptable nor feasible in many of such patients.
\nTherefore, surgical risks must be weighed against life expectancy and quality of life, in order to justify standard surgical interventions.
\nRecent advances in surgical techniques and percutaneous instrument placement have led to the development of minimally invasive approaches for the treatment of spinal metastases; these result in less post-operative pain, shorter overall hospital stays, less intra-operative blood loss, and an earlier start of adjuvant therapy [2, 11–14].
\nThe reported advantages of these techniques include smaller incisions, which limit wound complications, and the avoidance of back muscles detachment and retraction that causes post-operative pain and profuse bleeding, thus, reducing the need of intra or post-operative blood transfusion. These advantages are crucial for maintaining and improving the quality of life of cancer patients with short- or mid-term life expectancy [15–17].
\nMISS technique has the aim to perform (1) percutaneous insertion of pedicle screws and rods; (2) small exposure and detachment of the para-spinal muscles, to avoid their denervation and devascularization; (3) a mini-open midline approach to decompress the spinal cord, reducing bleeding and post-operative pain.
\nStandard open techniques require the full exposure of the posterior elements of the involved segments, with complete exposure of facet joints, thus resulting in much more aggressive damage to the back muscles and soft tissues.
\nOur procedure is first based on the placement of purely percutaneous pedicle screws; using a double x-ray arch, a four-handed surgery was performed, in order to reduce the operation time and minimize the radiation exposure.
\nA mini-open median posterior approach to expose only spinous process and laminae of the involved segments is then performed. A laminotomy, without the removal of the spinous process, just in case it was not infiltrated, is performed; the posterior joints are not exposed and removed to reduce the muscle detachment and retraction (which produces an excessive bleeding).
\nThe advantage of MISS techniques, in achieving an early better quality of life, seems to be related to their ability to reduce post-operative pain for both surgical-related and spinal metastasis-related components.
\nCriticism remains, regarding the reported difficulty of MISS to decompress enough spinal cord in case of spinal canal invasion; this persuasion is due to the erroneous conviction that the larger the surgical exposure, the better results achieved. On the contrary, in fact, MISS techniques permit an easy access to the spinal canal and complete spinal cord decompression and roots if needed.
\nTwo series of cancer patients, with a mBS 1 or 2, presenting acute myelopathy due to vertebral thoracic metastases have been compared. The first group were composed of patients prospectively enrolled from May 2010 to December 2013 and treated with MISS procedures (MISS) (n=29); the second group was composed of retrospectively collected patients treated with a traditional open surgery (OS) (n=25). Patients with complete neurological deficit (ASIA A) for more than 24 hours and a mBS >2 were excluded from present study.
\nFor both groups (n = 48, 32 women and 16 men, with a mean age of 54.6 yrs), the primitive tumors were: lung cancer (n = 17, 35.4%), breast cancer (n = 15, 31.2%), myeloma (n = 4, 8.3%), clear cell renal carcinoma (n = 3, 6.2%), melanoma (n = 3, 6.2%), prostate cancer (n = 2, 4%), ovarian cancer (n = 1, 2%), and thyroid cancer (n = 1, 2%) (Table 1).
\n\n | Group | \nOPEN | \nMISS | \nTotal | \np value | \n
---|---|---|---|---|---|
Demographic data | \n|||||
\n | Patients | \n19 | \n29 | \n48 | \n\n |
\n | Sex ratio (M/F) | \n7:12 | \n9:20 | \n16:32 | \n\n | \n
\n | Mean Age | \n51.74 | \n57.60 | \n54.65 | \n\n | \n
Clinical data | \n|||||
\n | Karnowsky | \n57.89% | \n55.36% | \n56.09% | \n0.94 | \n
\n | Modified Bauer | \n2.6 | \n2.3 | \n2.4 | \n0.135 | \n
Spinal metastases | \n|||||
\n | Single level | \n14 (73.6%) | \n18 (62.0%) | \n32 (66.6%) | \n\n | \n
\n | Two or more level | \n5 (26.3%) | \n11 (37.9%) | \n16 (33.3%) | \n\n | \n
\n | One column | \n10 (52.6%) | \n9 (31.0%) | \n19 (39.5%) | \n\n | \n
\n | Two or more column | \n9 (47.4%) | \n20 (68.9%) | \n29 (60.4%) | \n\n | \n
Primary cancer | \n|||||
\n | Lung | \n8 (42%) | \n9 (31.0%) | \n17 (35.4%) | \n\n | \n
\n | Breast | \n6 (31.6%) | \n9 (31.0%) | \n15 (31.2%) | \n\n | \n
\n | Mieloma | \n\n | \n4 (17.4%) | \n4 (8.3%) | \n\n | \n
\n | Kidney | \n2 (10.5%) | \n3 (10.3%) | \n3 (6.2%) | \n\n | \n
\n | Melanoma | \n\n | \n3 (10.3%) | \n3 (6.2%) | \n\n | \n
\n | Prostate | \n2 (10.5%) | \n\n | 2 (4%) | \n\n | \n
\n | Ovary | \n1 (5.3%) | \n\n | \n1 (2.0%) | \n\n | \n
\n | Thyroid | \n\n | 1 (3.4%) | \n1 (2.0%) | \n\n | \n
The clinical and oncological data of all the patients and divided by group.
Thirty two patients had one single level involved (66.6%), while 16 patients had a diseases extended to two or more segments (33.3%). In 19 patients (39.5%), the fracture involved a single column (OS: 52.6%, MISS: 31.0%), while two or three columns were substituted by cancer in 60.4% (Table 1).
\nThe two groups were homogeneous, in terms of general and neurological conditions. All patients preoperatively presented an overall mean KPS of 56%, with 57.89 and 55.36% in the OS and MISS groups, respectively (p = 0.9); the mean overall mBS was 2.4 (2.6 and 2.3 in the OS and MISS group, respectively, p = 0.18) (Table 1). Pre- and post-operative ASIA scores for both groups are reported in Table 2.
\n\n | Group | \nOPEN | \nMISS | \nTotal | \nP value | \n
---|---|---|---|---|---|
ASIA | \n|||||
Pre-op | \n|||||
\n | A | \n3 | \n3 | \n6 | \n\n |
\n | B | \n2 | \n4 | \n6 | \n\n | \n
\n | C | \n6 | \n9 | \n15 | \n\n | \n
\n | D | \n8 | \n13 | \n21 | \n\n | \n
\n | E | \n0 | \n0 | \n0 | \n\n | \n
Post-op | \n|||||
\n | Improved | \n12 (63%) | \n18 (62.0%) | \n30 (62.5%) | \n\n | \n
\n | Stable | \n6 (31%) | \n9 (31.0%) | \n15 (31.2%) | \n\n | \n
\n | Worse | \n1 (5%) | \n2 (6.7%) | \n3 (6.2%) | \n\n | \n
P value | \n\n | \n | \n | 0.001 | \n0.54 | \n
EORTC | \n|||||
QLQ-C30 | \n|||||
QoL | \n|||||
\n | Pre-op | \n16.00% | \n16.90% | \n16.60% | \n\n | \n
\n | Post-op | \n25.80% | \n32.10% | \n28.90% | \n\n | \n
P value | \n\n | \n | \n | 0.01 | \n\n | \n
Functional scales | \n|||||
\n | Pre-op | \n59.10% | \n55.10% | \n57.10% | \n\n | \n
\n | Post-op | \n72.60% | \n70.90% | \n71.70% | \n\n | \n
P value | \n\n | \n | \n | 0.04 | \n\n | \n
Symptom scales | \n|||||
\n | Pre-op | \n33.00% | \n34.10% | \n33.50% | \n\n | \n
\n | Post-op | \n15.80% | \n15.10% | \n15.40% | \n\n | \n
P value | \n\n | \n | \n | 0.009 | \n\n | \n
QLQ-BM22 | \n\n | \n | \n | \n | \n |
\n | Functional scales b | \n\n | \n\n | \n\n | \n\n | \n
\n | Pre-op | \n75.15% | \n72.90% | \n74.00% | \n\n | \n
\n | Post-op | \n79.80% | \n85.10% | \n82.45% | \n\n | \n
P value | \n\n | \n | \n | 0.025 | \n\n | \n
\n | Symptom scales b | \n\n | \n\n | \n\n | \n\n | \n
\n | Pre-op | \n16.65% | \n18.10% | \n17.37% | \n\n | \n
\n | Post-op | \n8.20% | \n5.90% | \n7.05% | \n\n | \n
P value | \n\n | \n | \n | 0.001 | \n\n |
The pre-operative and post-operative neurological data (ASIA) and the quality of life data (EORTC QLQ-C30 and QLQ-BM22) of all the patients and divided by group.
The pre-operative neurological assessment showed a prevalence of ASIA D in both groups.
\nThirty patients (62.5%) showed an improvement of neurological status, while 15 patients were stable (31.2%), and only 3 patients (6.2%) worsened. No statistically significant differences in terms of neurological improvement were demonstrated between the two groups (p = 0.54). The neurological conditions for only three patients (7.1%) (1 from the OS group, and 2 from the MISS group) worsened; these results were not due to surgical-related complications, but to bad general conditions.
\nSurgical and hospitalization data are given in Table 3.
\nGroup | \nOPEN | \nMISS | \n\n |
---|---|---|---|
Surgery data | \n|||
Operative time | \n3.2 h (2.5–4.5 h) | \n2.1 h (1.5–3 h) | \n\n | \n
Blood loss | \n900 ml (350–1500 ml) | \n140 ml (50–250 ml) | \n\n | \n
Hospitalization | \n|||
Blood supply | \n12 pts | \n0 pt | \n\n | \n
Complication | \n0 pt | \n1 pt | \n\n | \n
Post-op bed-rest | \n4 d (2–10 d) | \n2 d (1–3 d) | \n\n | \n
Discharge | \n9.25 d (5–14 d) | \n7.3 d (4–9 d) | \n\n | \n
Death | \n1 pt | \n0 pts | \n\n | \n
\n | \n\n | \n\n | \nP value < 0.01 | \n
Surgical and hospitalization data divided by group.
There were no serious peri-operative complications, in the MISS group; only one patient developed a post-operative urinary infection. In the OS group, 1 patient died on the 14th post-operative day, due to metastatic hepatic failure. The mean operation length was 3.2 h and 2.1 h respectively in the OS group and in the MISS group (p < 0.01).
\nThe mean intra-operative blood loss was 900 mL in the OS group and 140 mL in the MISS group (p < 0.01). Twelve patients in the OS group required post-operative RBC transfusions, while no one in the MISS group required additional blood supply. The mean post-operative bed-rest time was 4 days with a mean length of hospitalization of 9.25 days in the OS group, while the mean post-operative bed-rest time was 2 days with a mean length of hospitalization of 7.3 days in the MISS group (p < 0.01).
\nPre-operative scoring for quality of life (QoL) was homogeneous in both groups, according to the EORTC QLQ-C30 and EORTC QLQ-BM22 scales (Table 2). At follow-up, the analysis of EORTC QLQ-C30 questionnaire showed a mean overall improvement of 12.3% in QoL score (OS: 9.8%, MISS: 15.2%, p = 0.01), 14.6% in the functional scale score (OS: 13.5%, MISS: 15.8%, p = 0.04), and 18.1% for the symptoms scale score (OS: 17.2%, MISS 19%, p = 0.009). The evaluation of QLQ-BM22 scale showed a mean overall improvement at follow-up of 8.45% in the functional scale score (OS: 4.65%, MISS: 12.2%, p = 0.025), and 10.32% in symptoms scale score (OS: 8.45%, MISS: 12.2%, p = 0.001). The pre-operative VAS scores did not significantly differ between the groups (p > 0.015) (Table 4).
\n\n | Group | \nOPEN | \nMISS | \nTotal | \n
---|---|---|---|---|
VAS | \n||||
Pre-op | \n||||
\n | 0–20 | \n2 | \n3 | \n5 | \n
\n | 40 | \n4 | \n4 | \n8 | \n
\n | 60 | \n6 | \n11 | \n17 | \n
\n | 80 | \n3 | \n6 | \n9 | \n
\n | 100 | \n4 | \n5 | \n9 | \n
Post-op | \n\n | \n | \n | \n |
\n | Improved | \n10 (53%) | \n21 (72%) | \n31 (65%) | \n
\n | Stable | \n7 (37%) | \n7 (24%) | \n14 (29%) | \n
\n | Worse | \n2 (10%) | \n1 (4%) | \n3 (6%) | \n
P value | \n\n | \n | \n | 0.015 | \n
ANTALGIC | \n||||
Pre-op | \n\n | \n | \n | \n |
\n | Ad lib. | \n2 | \n3 | \n5 | \n
\n | NSAID | \n10 | \n14 | \n24 | \n
\n | Morphine | \n7 | \n12 | \n19 | \n
Post-op | \n||||
\n | Ad lib. | \n10 | \n18 | \n28 | \n
\n | NSAID | \n4 | \n8 | \n12 | \n
\n | Morphine | \n5 | \n3 | \n8 | \n
P value | \n\n | \n | \n | 0.01 | \n
The pre-operative and post-operative clinical data (VAS) and drug data (ANTALGIC) of all the patients and divided by group.
At follow-up, 31 patients (65%) showed an improvement of VAS score (OS: 53%, MISS: 72%), while 14 patients (29%) were stable (OS: 37%, MISS: 24%), and 3 patients (6%) worsened (OS: 10%, MISS: 4%) (p = 0.007).
\nIn the pre-operative period, five patients received ad libitum administration of antalgic drugs, and 28 patients received it at follow-up (OS: 10, MISS: 18). 24 patients were pre-operatively administered NSAIDs, while 12 patients received NSAIDs at follow-up (OS: 4, MISS: 8). Nineteen patients were pre-operatively administered morphine, while eight patients were administered morphine at follow-up (OS: 5, MISS: 3) (p = 0.01).
\nClinical case #1. Pre-operative MRI axial, CT axial and MRI sagittal scan (A, B and C) showed an osteolytic lesion which substituted the T12 body and its right pedicle, with initial invasion of the spinal canal. In the D and E images it is shown the postoperative CT scan in the axial and coronal plane which documented the percutaneous short fixation with transpedicular screws at T11, L1, and at the left pedicle of T12, followed by a mini-open access, centered at the level of T12, with a decompressive right laminotomy. Skin incisions in the F image.
A 75-year-old with a two-year history of white cell renal carcinoma, already treated with chemo- and radio-therapy, presented with sudden leg weakness, hyper-reflexia, and urge-incontinence (ASIA C, KPS 60, mBS 2), after a one-month history of severe thoracic spinal pain (VAS 90/100), unresponsive to common analgesics. Imaging showed a lesion which substituted the T12 body and its right pedicle, with initial invasion of the spinal canal. He then underwent a pure percutaneous short fixation with transpedicular screws at T11, L1, and at the left pedicle of T12, followed by a mini-open access, centered at the level of T12, with a decompressive laminotomy.
\nThe patient was mobilized in the first post-operative day, with an almost complete resolution of thoracic pain (VAS 20/100). Intraoperative blood loss was 200 cc, and RBC transfusion was not necessary. No opioids were administered in the post-operative period, and the patient was discharged on the fourth post-operative day. A post-operative CT scan showed the complete decompression of the spinal cord, with segmental fixation. At the follow-up, the patient presented a complete restoration of neurological deficit (ASIA E), and antalgic therapy with non-steroidal anti-inflammatory drugs (NSAID) was only administered ad libitum (\nFigure 2\n).
\nClinical case 2. Pre-operative MRI sagittal scan and coronal thoraco-lumbar X-ray (A and B images) showed diffuse spinal metastatic localizations with pathologic fractures of T9, T10 and T11, severe kyphosis and medullary compression in patient with a previous right partial T10 corpectomy with T9-T11 antero-lateral fixation. In the C and D images it is shown the postoperative CT scan 3D reconstruction which documented the percutaneous fixation with transpedicular screws at T7, T8, left pedicle of T9, L1 and L2, followed by a mini-open access, centered at the level of T10-T11, with a decompressive laminotomy and double cross-link. Skin incisions in the F image.
A 77-year-old woman, with a seven-year history of follicular thyroid cancer and previous lung and spine metastases that were treated with left inferior pulmonary lobectomy and right partial T10 corpectomy with T9-T11 antero-lateral fixation, respectively, came to our attention, having a new onset of severe thoraco-lumbar pain (VAS 90/100) with leg weakness (ASIA C). The free interval of disease was three years, after the conclusion of adjuvant chemo- and radio-therapy. Imaging showed diffuse spinal metastatic localizations with pathologic fractures of T9, T10 and T11; a severe kyphosis of the dorsal spine was evident. MRI results also showed spinal cord compression at T10-T11 levels, due to extradural metastatic tissue and progressive kyphosis (ASIA C, KPS 60, mBS 2).
\nThe patient underwent a pure percutaneous fixation by transpedicular screws at T7, T8, L1 and L2, while at T9 only on the left pedicle was screwed; a mini-open access, centered at the level of T10-T11, was performed with decompressive laminotomy and positioning of two cross-links. The patient was mobilized in the first post-operative day. Intraoperative blood loss was only 350 cc. No opioids were administered in the post-operative period, and the patient was discharged on the eighth post-operative day. A CT scan, performed at the discharge, showed the complete decompression of the spinal cord and the final fixation. At follow up, the neurological conditions improved (ASIA D), and opioids were stopped, in order to start antalgic therapy with NSAID (\nFigure 3\n).
\nResults of our comparative study demonstrate that standard open techniques and the MISS techniques are equivalent, in terms of the ability to achieve an early neurological improvement in patients with acute myelopathy due to spinal cord compression. Nevertheless, MISS approach has a clear and significant advantage over standard open techniques, in terms of blood loss, operation length, and hospital stay; they also confirm its safety, with no patients presenting peri-operative surgical-related complications.
\nThe study consisted of 48 patients with advanced cancer from different primary tumors, presenting a low Karnowsky score and acute myelopathy due to spinal-cord compression; All of them had low modified Bauer scores, which indicate only a short or middle term surgical palliation through posterior decompression and spinal segmental fixation [18]. Surgery was instrumented in all patients, to treat a preoperative instability or to prevent post-surgical instability. A gross total or complete resection of metastases was never attempted because clearly not indicated for any of the patients in the series.
\nAccording to the biological behavior of the lesion (i.e., osteolytic or osteoblastic), the number of segments involved, and the columns involved for each segment, the implant for fixation was as shortest as possible, and, in cases where the lesion was partially invading the vertebra, pedicle screws are also inserted in the fractured vertebrae.
\nWe have been interested in comparing the quality of life at an early follow-up, since, in patients with advanced metastatic cancer, the late follow-up is generally conditioned by the progression of the primary disease, and this can produce a bias when evaluating the surgical results for neurological restoration alone or the quality of life. Considering an equivalent neurological recovery, at 30 days follow-up, patients in the MISS group presented a better outcome in terms of quality of life: in our opinion this is the final aim of surgical treatment in case of patients with short- to mid-term life expectancy.
\nInterestingly some patients of our series aged over 60 years presented an early worsening of neurological symptoms, confirming that age is a key prognostic factor which must to be considered before choosing the surgical strategy in treating advanced cancer patients.
\nFinally, MISS seem to significantly reduce the post-operative pain. In fact, in our series, VAS reduced and the need for opioids was significantly lower in patients of the MISS group. The reduction in opioids administration improves the quality of life of such patients, avoiding severe constipation or alterations in consciousness.
\nIn our experience, metastatic patients operated with MISS techniques, compared to those operated with traditional open surgery techniques, presented a significant improvement in term of blood loss, operation time, and bed rest length, which is associated to a more rapid functional recovery and discharge from hospital. The post-operative pain and the need of opioids administration were also significantly less pronounced, and these effects appear to translate to a better quality of life of such patients, which is a primary aim in case of patient with a short life expectancy.
\nSince the time immemorial, human society has been dependent on foods for their existence. We derive a variety of foods from plants and animals such as sea-foods, eggs, fishes etc. All these are consumed by man to satisfy their nutritional requirements, proper body growth and development, health and to increase their appetite value. But the food items of animal origin are perishable in nature as a result they get spoiled due to microbial activity. Hence to reduce this toxicity of food ‘hurdle technology’ was developed several years ago for the production of safe, stable, nutritious, tasty and economical foods. The hurdle technology, also called combined methods or combined processes, is an integrated approach of basic food preservation methods for making the food more safe, stable and nutritious [1]. It can also be defined as a method of achieving control or elimination of pathogens present in the foods for creating safe and shelf - stable food. The concept of hurdle technology is quite old but has been used by many countries across the globe including India for effective preservation of foods. It advocates the wise use of a combination of different preservation factors or techniques termed as hurdles in order to achieve multi-target, mild but reliable preservation effects in foods. Hurdle technology developed with the concept to address the consumer demand to provide more natural and fresh food. According to Leistner [2] hurdle technology is the process of an intelligent combination of hurdles which safeguards the microbial safety and storage stability along with retains the sensory, nutritional quality and economic viability of food materials. It has come in response to several number of developments viz.,
To fulfill consumers’ demand for improved foods that retain their unique nutritional properties with freshness.
This technology shift food products ready-to-eat and makes it convenience foods with lesser processing requirements by consumers.
Basically, consumers prefer more ‘natural food products’ which requires less processing effort with use of minimum chemical preservatives.
It offers a framework for merging a number of milder preservation techniques to attain an improved level of product safety with longer stability (dimorianreview.com).
The hurdles technology can be applied in several fish and fishery products such as the salted fish, smoked, marinated products, pickles, canned fish products (high or low temperature), traditional Asian sauces (fermentative microorganisms) and more recently, in vacuum-packed products (redox potential). These preservative factors have been studied for several years ago. Hurdles technology have some prose (by inhibiting microorganisms) along with some cons (on other parameters such as nutritional properties or sensory quality), depending on their intensity. For example, salt content in food must be in such a limit to inhibit pathogens and spoilage microorganisms, but not too high to impair taste and act as pro-oxidants [3].
Improves foodstuffs quality and ensures microbial activity.
Food remains safe and stable for a longer duration of time.
It is high in sensory and nutritive value due to hurdle effects.
It is applicable in both small- and large-scale industries.
Does not change the composition or integrity of food items.
It fulfills the current demands of the consumers for fresh, natural and minimally processed foodstuffs.
It is economically suitable for the nation as it saves money, time, energy and other resources.
Food preservation techniques are an inseparable part of production of foodstuffs in order to overcome or counter the pathogen activities. Thus, the food scientist applied combined use of several preservation methods including physical or chemical which is an age-old practice. This is generally used by the food industry to ensure food safety and stability. Seafood in terms of fresh fish which is a highly perishable product due to its chemical composition and high accumulation of microorganisms on its body surface. In 1976, Leistner introduced the term “Hurdle effect”. Leistner and co-workers acknowledged that the hurdle concept illustrates the well - known fact that the complex interactions of temperature, water activity, pH, redox potential, etc. are significant for the microbial stability of foods [4].
Hurdle is defined as a factor, a condition, or a processing step that limits, or prevents the microbial growth and reduce microbial load. There are many preservation methods used for making foods stable and safe e.g., heating, chilling, freezing, freeze drying, drying, curing, salting, sugar addition, acidification, fermentation, smoking and oxygen removal. Currently, more than 50 hurdles are used in food processing industries throughout the world. Some of the principle hurdles used for seafood products are given in Table 1. The hurdle effect is the most fundamental importance for the preservation of foods, since the hurdles in a stable product, control the microbial spoilage, food poisoning and desired fermentation processes [5]. If the intensity of a particular hurdle in a food is too small, it should be strengthened, and in case, it is detrimental to the food quality.
Parameter | Symbol | Application |
---|---|---|
High temperature | F | Heating |
Low temperature | T | Chilling, freezing |
Reduced water activity | aw | Drying, curing, conserving |
Increased acidity | pH | Acid addition or formation |
Reduced redox potential | Eh | Removal of oxygen or addition of ascorbate |
Bio preservatives | — | Competitive flora such as microbial fermentation |
Other preservatives | — | Sorbates, sulphites, nitrites |
Principle hurdles used for food preservation.
The preservative factors or hurdles disturbs the homeostatis of microorganisms.
Pathogens should not be allowed to cross or jump over all the hurdle effects present in the food items.
Preservative factors should not allow the microorganisms to proliferate and remain in an inactive stage or even kill them.
The hurdle effect shows that the complexity of interactions of temperature, water, pH, humidity are important factors to microbial stability.
The hurdle technology affects the physiology and growth of microorganisms in food. There are mainly 4 major mechanisms by which hurdle technology affects the growth of microorganisms in foods, these are -
Basic aspects of hurdle technology [
The literal meaning of “homeostasis” is “same state” and it refers to the process of keeping the internal body environment in a steady state, when the external environment is changed. In case of food preservation techniques, if somehow the homeostasis of the pathogens are disturbed, then they will not be able to proliferate themselves. They will remain in the lag phase or even die until their internal body temperature is maintained or recovered [7]. But microorganisms can acquire myriad routes to reach their homeostatic state. Thus, the most effective way to prevent their growth on food items is to go through combined methods of hurdle effect. Disturbing the homeostasis of the microorganisms by various hurdles eventually results in the death of the spoilage causing microbes thereby protecting the food product from microbial spoilage.
Auto-sterilization of food products can be achieved by metabolic exhaustion, which leads to the death of the germinated spores and thus ensuring the success of hurdle technology. There are a number of different types of bacteria, mold and yeast which overcome and sustain the high temperature. Many bacterial spores which survive the thermal treatment are able to germinate in similar food products under unfavorable conditions than those under which vegetative bacteria are able to multiply [8]. Therefore, the microorganisms in the food products try every possible way to repair mechanisms for their homeostasis. By doing this, they completely use up their energy and die. This leads to auto-sterilization of foods. When multiple hurdles are applied in the food items, the rate of metabolic exhaustion is accelerated. In this due course, high energy is required by the microorganisms to maintain their homeostasis which is not achieved by them. Thus, it leads to microbial cell damage and inhibits their further growth [9].
Due to generation of shock proteins, some bacteria become more and more virulent under stress conditions. The stress shock proteins are a family of proteins that are produced by the cells in response to exposure to stressful conditions, induced by heat, pH, aw, ethanol, oxidative compounds, cold, UV light and starvation. Then, the simultaneous exposure to different stresses of bacteria will require high energy demand or at least much more protective stress shock proteins, which ultimately causes the death of the microorganisms [10]. Exposure to the multiple stresses simultaneously induces energy utilizing and synthesis of several stress shock proteins, in turn making the microbes metabolically weak. Hence, multitarget preservation of foods could be an efficient approach for minimizing the production of stress shock proteins and in food preservation for long term [2].
Leistner [11] has been developed the concept of “Multi-target preservation of food” which is a most significant aspect for efficient and effective preservation of targeted food products. Hurdles which are applied in the targeted food products might not just have effects on microbial stability but also it act synergistically [11]. The synergistic effect could be attained in the targeted food products, if the combined effects of different hurdles viz., pH, aw, Eh, enzyme systems targets simultaneously within the microbial cell and thus disturb the homeostasis of the microbes. This phenomenon interpreting and difficult for the microbes to synthesize a number several stress shock proteins and to maintain their homeostasis [4]. Hence the application of multiple hurdles technique simultaneously would lead to an optimal microbial stability and effective food preservation.
The main objective of this technology is food preservation, storage of food products and enhancement of their shelf life thereby giving us good quality products. There are several reasons for preserving the foods which are as follow (i) To ensure the safety of food from microbes (ii) To prevent the spoilage of food (iii) To enhance the keeping quality of food (iv) To control food borne infections and intoxications (v)To extend the shelf life of food (vi) To reduce economic losses [12].
Every stable and safe food and food products are having several sets of intrinsic hurdles which differs in quality and intensity based on a particular product, however, in any case the hurdles must keep the ‘normal’ population of microorganisms in this food under control. The microorganisms present at the begging stage of food products, are incapable to jump over the next hurdles present in the food systems. Few examples of the hurdle effects depicted in Figure 2.
Illustration of the hurdle effect, using eight examples. Symbols have the following meaning: F, heating; t, chilling; aw, water activity; pH, acidification; eh, redox potential; pres., preservatives; K-F, competitive flora; V, vitamins; N, nutrients [
While applying hurdle technology for particular food product the selected processing method (preservation and packaging) will affect the spoilage mechanism and leads to the major quality deterioration fish and fishery product. For example, the fish preserved by cold smoking process the combination of hurdles includes salt addition, mild thermal treatment and storage at low temperatures, in this case the quality deterioration is mainly attributed to microbial spoilage, resulting in sensory modifications and thus organoleptic rejection. However, when same food products stored at subzero temperatures then the quality deterioration is correlated with physical and chemical reactions, viz., dehydration and lipid oxidation. These are major factors that defining duration of shelf life of the final products [13].
The Southeast Asian countries are well-known for fermented fish products and preservation, similarly in India the northeast region is famous for same [14]. These areas are in rich natural resources and a cauldron of different people and cultures lie deep in the lap of easternmost Himalayan hills [15]. A number of hurdles are used for preparation of the fermented fish products, these hurdles makes the food products more stable, with enhanced sensory quality and are safe at room temperature. According to Erkmen & Bozoglu (2016) [16], the storage stability of fermented fish products could be attained by applying a combination of hurdles at several stages of the manufacturing process.
The fish and fishery products preserved by freezing and stored under frozen condition, it can provide a storage life of more than one year, if appropriately carried out. It has enabled fishing vessels to remain at sea for long periods, and allowed the storing of fish during periods of good fishing and high catching rates, as well as extended the market for fish products of high quality (http://www.fao.org/3/v3630e/v3630e03.htm) [17]. However, it has been reported that the temperature conditions in the actual cold chain often deviate from the recommended range. For this reason, the preservation of refrigerated fish products is alone is not sufficient. During the past years, the fish mainly gutted fish and fillets are stored under modified atmospheres or in vacuum. According to Tsironi & Taoukis (2010), it has been found that the combined application of modified atmospheres with the low aw by applying osmotic dehydration along with addition of nisin in the osmotic solution may significantly extend the shelf life of refrigerated gilt-head seabream fillets during storage at 0–15°C.
Preservation by heat is a major method for extending the shelf life of packaged fish because of the advantages of a high safety level, convenience and a healthy product. In thermal processing, food is preserved in hermetically sealed containers in cooked form for storage at ambient temperature, without compromising on the quality. It’s mainly depends on hurdle technology and the final products exhibit usually very long storage stability. According to Choulitoudi et al. (2017) [18] the combined application of hot smoking and edible coating based active packaging enhanced by the incorporation of rosemary essential oil and/or extract at refrigerated storage under vacuum on eel fillets.
The quality of fish and fishery products is of major concern to the seafood processors, consumers and public health authorities. The quality of fish degrades, due to a complex process mainly by physical, chemical and microbiological forms of deterioration are implicated. However, some sea foods are processed in a modern fish industry which is technologically advanced and complicated industry in line with any other sea foods industry and with the same risk of products being contaminated with pathogenic microorganisms [19]. However, the greatest risk to human health is due to the consumption of spoiled fish, improper processed, improper preserved fish and fish products. There are several methods of fish preservation and processing one of the among hurdle technology is applied in seafood processing which ensure seafood safety. This technology ultimately improves the public health from food posing, seafood borne pathogen, food borne illness.
The main advantage of this technique is affinity to overcome the ability of microorganisms in developing resistance to conventional preservation methods since this technique using combination of different preservation technique which acts synergistically by hitting different targets within the cell of the spoilage microorganism.
Basically, in this technique, hurdles are use at lower concentrations this prevent the undesirable sensory changes and also provide the lower production cost and save energy.
Another advantage of this technique is using natural preservatives in combination with synthetic preservatives, this also lower the risk associated with using synthetic preservatives at high concentration.
Possibility of increasing shelf-stable foods; because food preserved by combined methods (hurdles) remains stable and safe even without refrigeration, and is high in sensory and nutritive value due to the gentle process applied.
Hurdles used in seafood preservation can provide various degree of microbial stress reactions, these stress reactions or cross-tolerance may not work when multiple hurdles are used. Mainly three type of possible results while applying hurdles technology for seafood preservation [20].
Addition or additive effect,
Synergism or synergistic effect,
Antagonism or antagonistic effect.
Here the term additive effect imply that effects of the individual substances are simply added together. Generally, the combination of hurdles has a higher inhibitory effect than any single one. Synergistic effect means that the inhibitory action of the combination of hurdles at intensity lower than that of the constituent hurdles separately. In an antagonistic effect, the needed hurdle level is stronger than that of the single constituents. Sometimes combination treatments are not much effective in lowering microorganisms than single treatments. These effects of combined hurdles are antagonistic. In some cases, application of the hurdle technology for seafood preservation may inhibit outgrowth but induced tolerance capability of microorganism and hence extended their survivability [20].
This hurdle technology is an effective and simple method in food preservation fields but it requires strategic processes. It is an important approach that can be used to improve quality parameters during processing and storage of food. Hurdle technology Smart application of hurdles improve sensory characteristics, chemical and microbiological qualities of food. Hurdles in the food preservatives require varying results on the basis of microbial stress. Undoubtedly, it will help in fulfilling the demand for fresh and natural food products. It will actually slow the emergence of new routes of microorganisms in the food items and thus keeps the foods safe and healthy to eat.
All Authors are thankful to Dean College of Fisheries Science Gumla Birsa Agricultural University Kanke Ranchi Jharkhand for encouragement and guidance during writing of this book chapter.
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