Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases

Predictors for quality of life, pain and functional outcomes after surgical treatment of metastatic disease in the spine

BACKGROUND

While predictors for postoperative survival in spine tumour patients have been identified, there is limited evidence for predictors of postoperative Quality of Life (QoL), pain and functional outcome.

METHODS

One hundred and fifty-three consecutive patients, who had undergone surgery for symptomatic spinal metastases between June 2016 and April 2019, were interviewed preoperatively and during follow-ups at three, six and 12 months using the EQ-5D-3L, COMI, and ODI questionnaires. Differences in means exceeding the specific Minimal Clinically Important Difference (MCID) values were considered clinically significant.

RESULTS

Thirty-three percent of the patients were reported dead after 12 months. Only one metastasis compared to multiple metastases has 7.9 the Odds for an improved EQ-5D-3L score at three months. No neoadjuvant metastatic irradiation has 6.8 the Odds for the improvement at that time against performed radiation. A preoperative ODI score between 50.1 and 100 has 22.0 times the odds compared to the range from 0 to 50 for an improved EQ-5D-3L after three months, and 12.5 times the odds in favour of improved COMI after three months, and 13.6 times the odds for improvement of ODI at the three-month follow-up. A preoperative COMI score ranging from 5.0 to 10 has 21 times the odds of a COMI between 0 and 5 for an improved EQ-5D-3L score and 11 times the odds for an improved ODI after 12 months. Other predictors showed no statistically significant improvement.

CONCLUSION

An improvement in QoL, pain and spinal function after 12 months can be predicted by a subjective preoperative poor health condition. Impaired spinal function before surgery, a singular metastasis and no previous irradiation is predictive of improved spinal function and quality of life three months after surgery.

Monte Carlo Dosimetric Study of Percutaneous Vertebroplasty and Brachytherapy for the Treatment of Spinal Metastases

Background

Percutaneous vertebroplasty employs bone cement for injecting into the fractured vertebral body (VB) caused by spinal metastases. Radioactive bone cement and also brachytherapy seeds have been utilized to suppress the tumor growth in the VB.

Objective

This study aims to investigate the dose distributions of low-energy brachytherapy seeds, and to compare them to those of radioactive bone cement, by Monte Carlo simulation.

Material and Methods

In this simulation study, nine CT scan images were imported in Geant4. For the simulation of brachytherapy, I-125, Cs-131, or Pd-103 seeds were positioned in the VB, and for the simulation of vertebroplasty, the VB was filled by a radioactive cement loaded by P-32, Ho-166, Y-90, or Sm-153 radioisotopes. The dose-volume histograms of the VB, and the spinal cord (SC) were obtained after segmentation, considering that the reference dose is the minimum dose covered 95% of the VB.

Results

The SC sparing was improved by using beta-emitting cement because of their steep gradient dose distribution. I-125 seeds and Y-90 radioisotope showed better VB coverage for brachytherapy and vertebroplasty techniques, respectively. Pd-103 seeds and P-32 radioisotope showed better SC sparing for brachytherapy and vertebroplasty, respectively. The minimum mean doses that covered 100% of the VB were 62.0%, 56.5%, and 45.0% for I-125, Cs-131, and Pd-103 seeds, and 28.3%, 28.6%, 32.9%, and 17.7%, for P-32, Ho-166, Y-90, and Sm-153 sources, respectively.

Conclusion

I-125 and Cs-131 seeds may be useful for large tumors filling the entire VB, and also for the extended tumors invading multiple vertebrae. Beta-emitting bone cement is recommended for tumors located near the SC.

Prospective application of the risk analysis index to measure preoperative frailty in spinal tumor surgery: A single center outcomes analysis

Introduction

Surgeons are frequently faced with challenging clinical dilemmas evaluating whether the benefits of surgery outweigh the substantial risks routinely encountered with spinal tumor surgery. The Clinical Risk Analysis Index (RAI-C) is a robust frailty tool administered via a patient-friendly questionnaire that strives to augment preoperative risk stratification. The objective of the study was to prospectively measure frailty with RAI-C and track postoperative outcomes after spinal tumor surgery.

Methods

Patients surgically treated for spinal tumors were followed prospectively from 7/2020-7/2022 at a single tertiary center. RAI-C was ascertained during preoperative visits and verified by the provider. The RAI-C scores were assessed in relation to postoperative functional status (measured by modified Rankin Scale score [mRS]) at the last follow-up visit.

Results

Of 39 patients, 47% were robust (RAI 0-20), 26% normal (21-30), 16% frail (31-40), and 11% severely frail (RAI 41+).). Pathology included primary (59%) and metastatic (41%) tumors with corresponding mRS>2 rates of 17% and 38%, respectively. Tumors were classified as extradural (49%), intradural extramedullary (46%), or intradural intramedullary (5.4%) with mRS>2 rates of 28%, 24%, and 50%, respectively. RAI-C had a positive association with mRS>2 ​at follow-up: 16% for robust, 20% for normal, 43% for frail, and 67% for severely frail. The two deaths in the series had the highest RAI-C scores (45 and 46) and were patients with metastatic cancer. The RAI-C was a robust and diagnostically accurate predictor of mRS>2 in receiver operating characteristic curve analysis (C-statistic: 0.70, 95 CI: 0.49-0.90).

Conclusions

The findings exemplify the clinical utility of RAI-C frailty scoring for prediction of outcomes after spinal tumor surgery and it has potential to help in the surgical decision-making process as well as surgical consent. As a preliminary case series, the authors intend to provide additional data with a larger sample size and longer follow-up duration in a future study.

Survival Rate after Palliative Surgery Alone for Symptomatic Spinal Metastases: A Prospective Cohort Study

The effect of spine surgery for symptomatic spinal metastases (SSM) on patient prognosis remains unclear. This study aimed to reveal the prognosis of patients with SSM after spine surgery. One hundred twenty-two patients with SSM were enrolled in this prospective cohort study. The patients who received chemotherapy after enrollment were excluded. The decision of surgery depended on patient's willingness; the final cohort comprised 31 and 24 patients in the surgery and non-surgery groups, respectively. The patients were evaluated by their performance status (PS), activities of daily living (ADL) and ambulatory status. Survival was evaluated by the Kaplan-Meier method. The PS, ADL and ambulation were significantly improved in the surgery group compared to non-surgery group. The median survival was significantly longer in the surgery group (5.17 months, 95% confidence interval (CI) 3.27 to 7.07) than in the non-surgery group (2.23 months, 95% CI 2.03 to 2.43; p = 0.003). Furthermore, the patients with a better PS, ADL and ambulatory status had a significantly longer survival. Surgery improved the PS, ADL, ambulation and survival of patients with SSM. In the management of SSM, spine surgery is not only palliative but may also prolong survival.

Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations

INTRODUCTION

Peripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival.

HYPOTHESIS

Global function is improved by surgery, with acceptable survival.

MATERIAL AND METHOD

Between 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years' follow-up.

RESULTS

The most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8-17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2-8.9), prostate 11.1 months (95% CI: 5.3-43.6), kidney 12.9 months (95% CI: 8.4-22.6), breast 26.5 months (95% CI: 19.0-34.0), and thyroid 49.0 months (95% CI: 12.2-NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59-3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40-2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13-1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21-26.71 (p<0.001)).

CONCLUSION

Although function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates.

LEVEL OF EVIDENCE

IV; retrospective observational.

Spinal metastasis: narrative reviews of the current evidence and treatment modalities

The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.

Postoperative outcomes of minimally invasive pedicle screw fixation for treatment of unstable pathologic neoplastic fractures

STUDY DESIGN

Retrospective Case Series.

OBJECTIVES

Minimally invasive techniques have emerged as a useful tool in the treatment of neoplastic spine pathology due to decrease in surgical morbidity and earlier adjuvant treatment. The objective of this study was to analyze outcomes and complications in a cohort of unstable, symptomatic pathologic fractures treated with percutaneous pedicle screw fixation (PPSF).

METHODS

A retrospective review was performed on consecutive patients with spinal stabilization for unstable pathologic neoplastic fractures between 2007 and 2017. Patients who underwent PPSF through a minimally invasive approach were included. Surgical indications included intractable pain, mechanical instability, and neurologic compromise with radiologic visualization of the lesion.

RESULTS

20 patients with mean Tomita Score of 6.3 ± 2.1 points [95% CI, 5.3-7.2] were treated with constructs that spanned a mean of 4.7 ± 1.4 [95% CI, 4.0-5.3] instrumented levels. 10 (50%) patients were augmented with vertebroplasty. Majority of patients (65%) had no complications during their hospital stay and were discharged home (60%). Four patients received reoperation: two extracavitary corpectomies, one pathologic fracture at a different level, and one adjacent segment disease.

CONCLUSION

Minimally invasive PPSF is a safe and effective option when treating unstable neoplastic fractures and may be a viable alternative to the traditional open approach in select cases.

LEVEL OF EVIDENCE

4.

Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients

Objective

The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry.

Methods

The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients’ data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5.

Results

Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. ‘Severely frail’ patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21–35.44) for 30-day mortality, 3.02 (95% CI, 1.97–4.56) for major complications, and 2.94 (95% CI, 2.32–4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality.

Conclusion

Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

IMPACT OF SURGERY ON AMBULATORY STATUS IN PATIENTS WITH SYMPTOMATIC NEOPLASTIC SPINAL CORD COMPRESSION IN SOUTHERN BRAZIL

ABSTRACT Background: Spinal cord compression is a common complication of spine metastasis and multiple myeloma. About 30% of patients with cancer develop symptomatic spinal metastases during their illness. Prompt diagnosis and surgical treatment of these lesions, although palliative, are likely to reduce the morbidity and improve quality of life by improving ambulatory function. Study Design: Retrospective review of medical records. Objective: To evaluate postoperative functional recovery and the epidemiological profile of neoplastic spinal cord compression in two neurosurgical centers in southern Brazil. Methods: We retrospectively analyzed the data of all patients who underwent palliative surgery for symptomatic neoplastic spine lesion from metastatic cancer, in two neurosurgical centers, between January 2003 and July 2021. The variables age, sex, neurological status, histological type, affected segment, complications and length of hospitalization were analyzed. Results: A total of 82 patients were included. The lesions occurred in the thoracic spine in 60 cases. At admission, 95% of the patients had neurological deficits, most of which were Frankel C (37%). At histopathological analysis, breast cancer was the most common primary site. After surgery, the neurological status of 46 patients (56%) was reclassified according to the Frankel scale. Of these, 22 (47%) regained ambulatory capacity. Conclusion: Surgical treatment of metastatic spinal cord compression improved neurological status and ambulatory ability in our sample. Level of evidence II; Retrospective study.

Quantified CIN Score From Cell-free DNA as a Novel Noninvasive Predictor of Survival in Patients With Spinal Metastasis

Purpose: Most currently available scores for survival prediction of patients with bone metastasis lack accuracy. In this study, we present a novel quantified CIN (Chromosome Instability) score modeled from cfDNA copy number variation (CNV) for survival prediction. Experimental Design: Plasma samples collected from 67 patients with bone metastases from 11 different cancer types between November 2015 and May 2016 were sent through low-coverage whole genome sequencing followed by CIN computation to make a correlation analysis between the CIN score and survival prognosis. The results were validated in an independent cohort of 213 patients. Results: During the median follow-up period of 598 (95% CI 364-832) days until December 25, 2018, 124 (44.3%) of the total 280 patients died. Analysis of the discovery dataset showed that CIN score = 12 was the optimal CIN cutoff. Validation dataset showed that CIN was elevated (score ≥12) in 87 (40.8%) patients, including 5 (5.75%) with head and neck cancer, 11 (12.6%) with liver and gallbladder cancer, 11 (12.6%) with cancer from unidentified sites, 21 (24.1%) with lung cancer, 7 (8.05%) with breast cancer, 4 (4.60%) with thyroid cancer, 6 (6.90%) with colorectal cancer, 4 (4.60%) with kidney cancer, 2 (2.30%) with prostate cancer, and 16 (18.4%) with other types of cancer. Further analysis showed that patients with elevated CIN were associated with worse survival (p < 0.001). For patients with low Tokuhashi score (≤8) who had predictive survival of less than 6 months, the CIN score was able to distinguish patients with a median overall survival (OS) of 443 days (95% CI 301-585) from those with a median OS of 258 days (95% CI 184-332). Conclusion: CNV examination in bone metastatic cancer from cfDNA is superior to the traditional predictive model in that it provides a noninvasive and objective method of monitoring the survival of patients with spine metastasis.

Negative Pressure Wound Therapy in Facilitating Wound Healing after Surgical Decompression for Metastatic Spine Disease

BACKGROUND

The risk of wound related complications, including surgical site infections (SSIs), in patients undergoing surgery for metastatic spine disease (MSD) is high. Consequently, patients requiring wound revision surgery face delay in resuming oncological care and incur additional hospitalization. Recent reports suggest that negative pressure wound therapy (NPWT) applied on a closed wound at the time of surgery, significantly reduces post-operative wound complications in degenerative spine disease and trauma setting. Here, we report a single institution experience with incisional NPWT in patients undergoing surgery for MSD.

METHODS

We compared rates of wound complications requiring surgical revision in a surgical cohort of patients with or without NPWT from 2015 to 2020. Adult patients with radiographic evidence of MSD with mechanical instability and/or accelerated neurological decline were included in the study. NPWT was applied on a closed wound in the operating room and continued for 5 days or until discharge, whichever occurred first.

RESULTS

A total of 42 patients were included: 28 with NPWT and 14 without. Patient demographics including underlying comorbidities were largely similar. NPWT patients had higher rates of prior radiation to the surgical site (36% vs. 0%, p = 0.017) and longer fusion constructs (6.7 vs. 3.9 levels, p < 0.001). Three patients (21%) from control group and none from NPWT group contracted SSI requiring wound washout (p = 0.032).

CONCLUSIONS

Our data suggests that SSI and wound dehiscence are significantly reduced with the addition of incisional NPWT in in this vulnerable population.

National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014

Optimal management of metastatic lung cancer to the spine (MLCS) incorporates a multidisciplinary approach. With improvements in lung cancer screening andnonsurgical treatment, the role for surgerymay be affected. The objective of this study is to assess trends in the surgical management of MLCS using the National Inpatient Sample (NIS) database. The NIS was queried for patients with MLCS who underwent surgery from 2005 to 2014. The frequencies of spinal decompression alone, spinal stabilization with or without (+/-) decompression, and vertebral augmentation were calculated. Statistical analysis was performed to analyze the effect of patient characteristics on outcomes. The most common procedure performed was vertebral augmentation (10719, 44.3%), followed by spinal stabilization +/- decompression (8634, 35.7%) and then decompression alone (4824, 20.0%). The total number of surgeries remained stable, while the rate of spinal stabilizations increased throughout the study period (p < 0.001). Invasive procedures such as stabilization and decompression were associated with greater costs, length of stay,complications and mortality. Increasingcomorbidity was associated with increased odds of complication, especially in patients undergoing more invasive procedures. In patients with lowpre-operative comorbidity, the type of procedure did not influence the odds of complication. Graded increases in length of stay, cost and mortality were seen with increasing complication rate.The rate of spinal stabilizations increased, which may be due to either increased early detection of disease facilitating use of outpatient vertebral augmentation procedures and/or the recognition that surgical decompression and stabilization are necessary for optimal outcome in the setting of MLCS with neurological deficit.

Comparison of Minimally Invasive Tubular Surgery with Conventional Surgery in the Treatment of Thoracolumbar Metastasis

Background

This study aimed to evaluate the perioperative safety and efficacy of minimally invasive tubular surgery for patients with spinal metastasis.

Methods

A total of 161 consecutive patients with spinal metastasis between June 2017 and June 2020 were retrospectively reviewed. A total of 36 patients were included in this study, 14 patients underwent minimally invasive tubular surgery (M), and 22 patients underwent conventional surgery (C). T-test and chi-square tests were used to evaluate demographic and perioperative data differences between the two groups.

Results

Baseline characteristics did not differ significantly between M and C groups except for the SINS (p=0.002) and preoperative Alb (p=0.026). There was no significant difference in operative time and complications between M and C groups (p<0.05). The M group had less mean blood loss than the C group (1275 vs 718mL, p=0.045). Blood transfusion was comparable between the two groups (p<0.05). The mean amount and drainage time were lower than the C group (141 vs 873mL, p<0.001; 3.1 vs 7.0 days, P<0.001). The mean postoperative hospitalization of the M group was 8.8 days, which was lower than the C group (11.3 days, p=0.045). Sub-analysis showed that for patients with hyper-vascular tumor, the M group had less mean amount and time of drainage compared with the C group (p<0.05); for patients with hypo-vascular tumor, the mean blood loss and amount of blood transfusion were also reduced in M group (p<0.05). The mean blood loss and drainage time of patients with hypo-vascular tumors were less than patients with hyper-vascular tumors in the M group (p<0.05).

Conclusion

In selected cases, minimally invasive tubular surgery is safe and effective for patients with spinal metastasis. Patients with hypo-vascular tumors were more suitable for this technique with less blood loss, fewer blood transfusions, minor drainage, and shorter postoperative hospitalization.

Risk predictors of perioperative complications for the palliative surgical treatment of spinal metastasis

BACKGROUND

The complication rate for palliative surgery in spinal metastasis is relatively high, and major complications can impair the patient's activities of daily living. However, surgical indications are determined based primarily on the prognosis of the cancer, with the risk of complications not truly considered. We aimed to identify the risk predictors for perioperative complications in palliative surgery for spinal metastasis.

METHODS

A multicentered, retrospective review of 195 consecutive patients with spinal metastasis who underwent palliative surgeries with posterior procedures from 2001 to 2016 was performed. We evaluated the type and incidence of perioperative complications within 14 days after surgery. Patients were categorized into either the complication group (C) or no-complication group (NC). Univariate and multivariate analyses were used to identify potential predictors for perioperative complications.

RESULTS

Thirty patients (15%) experienced one or more complications within 14 days of surgery. The most frequent complications were surgical site infection (4%) and motor weakness (3%). A history of diabetes mellitus (C; 37%, NC; 9%: p < 0.01) and surgical time over 300 min (C; 27%, NC; 12%: p < 0.05) were significantly associated with complications according to univariate analysis. Increased blood loss and non-ambulatory status were determined to be potential risk factors. Of these factors, multivariate logistic regression revealed that a history of diabetes mellitus (OR: 6.6, p < 0.001) and blood loss over 1 L (OR: 2.7, p < 0.05) were the independent risk factors for perioperative complications. There was no difference in glycated hemoglobin A1c between the diabetes patients with and without perioperative complications.

CONCLUSIONS

Diabetes mellitus should be used for the risk stratification of surgical candidates regardless of the treatment status, and strict prevention of bleeding is needed in palliative surgeries with posterior procedures to mitigate the risk of perioperative complications.

Risk factors of total blood loss in the posterior surgery for patients with thoracolumbar metastasis

Background

Blood loss in posterior surgery patients with thoracolumbar metastasis posed a significant challenge to surgeons. This study aimed to explore the risk factors of blood loss in posterior surgery for patients with thoracolumbar metastasis.

Methods

One hundred forty-two patients were retrospectively reviewed. Their baseline characteristics were recorded. The Gross equation was used to calculate blood loss on a surgical day. Multivariate linear regression was used to analyze the risk factors.

Results

Mean blood loss of 142 patients were 2055 ± 94 ml. Hypervascular primary tumor (kidney, thyroid and liver) (P = 0.017), wide or marginal excision (en-bloc: P = 0.001), metastasis at the lumbar spine (P = 0.033), and the presence of extraosseous tumor mass (P = 0.012) were independent risk factors of blood loss in the posterior surgery. Sub-analysis showed that wide or marginal excision (en-bloc: P < 0.001) and metastasis at lumbar spine (P = 0.007) were associated with blood loss for patients with non-hyper vascular primary tumors. Wide or marginal excision (piece-meal: P = 0.014) and the presence of an extraosseous tumor mass (P = 0.034) were associated with blood loss for patients with hypervascular primary tumors.

Conclusion

Hypervascular primary tumor (kidney, thyroid, and liver) was an independent risk factor of blood loss in the posterior surgery. The presence of extraosseous tumor mass and wide or marginal excision (piece-meal) were independent risk factors for patients with hypervascular primary tumors. Metastasis at the lumbar spine and wide or marginal excision (en-bloc) were independent risk factors for patients with non-hyper vascular primary tumors.

A systematic review of MIS and open decompression surgery for spinal metastases in the last two decades

OBJECTIVE

The primary intention of this review being to produce an updated systematic review of the literature on published outcomes of decompressive surgery for metastatic spinal disease including metastatic spinal cord compression, using techniques of MIS and open decompressive surgery.

METHODS

The authors conducted database searches of OVID MEDLINE and EMBASE identifying those studies that reported clinical outcomes, surgical techniques used along with associated complications when decompressive surgery was employed for metastatic spinal tumors. Both retrospective and prospective studies were analysed. Articles were assessed to ensure the required inclusion criteria was met. Articles were then categorised and tabulated based on the following reported outcomes: predictors of survival, predictors of ambulation or motor function, surgical technique, neurological function, and miscellaneous outcomes.

RESULTS

2654 citations were retrieved from databases, of these 31 met the inclusion criteria. 5 studies were prospective, the remaining 26 were retrospective. Publication years ranged from 2000 to 2020. Study size ranged from 30 to 914 patients. The most common primary tumors identified were lungs, breast, prostate and renal cancers. One study ( Lo and Yang, 2017)¹³ reported that in those patients with motor deficit, survival was significantly improved when surgery was performed within 7 days of the development of motor deficit compared to situations when surgery was carried out 7 days after onset. This was the only study that showed that the timing of surgery plays a significant role w.r.t. survival following the onset of spinal cord compression symptoms. Four articles identified that a pre-operative intact motor function and or ambulatory status conferred a higher likelihood of a better post-operative outcome, not just in relation to survival but also in relation to post-operative ambulation as well as a greater tendency towards suitability for adjuvant treatment. Even for the same scoring system e.g. tokuhashi and its effectiveness in predicting survival, results from different studies varied in their outcome. The Karnofsky Performance Status (KPS) being the most commonly used tool to assess functional impairment, the Eastern Cooperative Oncology Group (ECOG) performance status being used in two studies. 23 studies identified an improvement in neurological function following surgery. The most common functional scale used to assess neurological outcome was the Frankel scale, 3 studies used the American Spinal Injury Association (ASIA) impairment scale for this purpose. Wound problems including infection and dehiscence appeared to be the most commonly reported surgical complication. (25 studies). The most commonly used surgical technique involved a posterior approach with decompression, with or without stabilisation. Less commonly employed techniques included percutaneous pedicle screw fixation associated with or without mini-decompression as well as anterior approaches involving corpectomy and instrumentation. 9 studies included in their data, the effect of radiation therapy in combination with surgery or as a comparison used as an alternative to surgery in spinal metastases.

CONCLUSIONS

We provide a systematic literature review on the outcomes of decompressive surgery for spinal metastases. We analyse survival data, motor function, neurological function, as well as the techniques of surgery used. Where appropriate complications of surgery are also highlighted. It is the authors' intention to provide the reader with a reference text where this information is ready to hand, allowing for the consideration of means and methods to improve and optimise the standard of care in patients undergoing surgical intervention for metastatic spinal disease.

Current trends in incidence, characteristics, and surgical management of metastatic breast cancer to the spine: A National Inpatient Sample analysis from 2005 to 2014

Management of metastatic breast cancer to the spine (MBCS) incorporates a multimodal approach. Improvement in screening and nonsurgical therapies may alter the trends in surgical management of MBCS. The objective of this study is to assess trends in surgical management of MBCS and short-term outcomes based on the National Inpatient Sample (NIS) database. The NIS database was queried for patients with MBCS who underwent surgery from 2005 to 2014. The weighted frequencies of spinal decompression alone, spinal stabilization +/- decompression, and vertebral augmentation were calculated. Multivariate analysis was performed to analyze the effect of patient characteristics on outcomes stratified by procedure. The most common procedure performed was vertebral augmentation (11,114, 53.4%), followed by stabilization +/- decompression (6,906, 33.2%) and then decompression alone (3,312, 13.4%). The total population-adjusted rate of surgical management for MBCS remained stable, while the rate of spinal stabilization increased (P < 0.001) and vertebral augmentation decreased (p < 0.003). The risk of complication increased with spinal stabilization and decompression compared to vertebral augmentation procedures in those with fewer comorbidities. This relative increase in risk abated in patients with higher numbers of pre-operative comorbidities. Any single complication was associated with increases in length of stay, cost, and mortality. The rate of in-hospital interventions remained stable over the study period. Stratified by procedure, the rate of stabilizations increased with a concomitant decrease in vertebral augmentations, which suggests that patients who require hospitalization for MBCS are becoming more likely to represent advanced cases that are not amenable to palliative vertebral augmentation procedures.

Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate differences in 30- and 90-day readmissions for spine metastases treated with decompression and/or fusion spine surgery in a nationwide readmission database.

SUMMARY OF BACKGROUND DATA

Patients with metastases to the spine represent a particularly vulnerable patient group that may encounter frequent readmissions. However, the 30- and 90-day rates for readmission following surgery for spine metastases have not been well described.

METHODS

The Nationwide Readmission Database years 2013 to 2015 was queried. Patients were grouped by no readmission (non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). Weighted multivariate analysis assessed impact of treatment approach and clinical factors associated with 30- and 90-day readmissions.

RESULTS

There were a total of 4423 patients with a diagnosis of spine metastases identified who underwent spine surgery, of which 1657 (37.5%) encountered either a 30-or 90-day unplanned readmission (30-R: n = 1068 [24-.1%]; 90-R: n = 589 [13.3%]; non-R: n = 2766). The most prevalent inpatient complications observed were postoperative infection (30-R: 16.3%, 90-R: 14.3%, non-R: 11.5%), acute post-hemorrhagic anemia (30-R: 13.4%, 90-R: 14.2%, non-R: 14.5%), and genitourinary complication (30-R: 5.7%, 90-R: 2.9%, non-R: 6.2%). The most prevalent 30-day and 90-day reasons for admission were sepsis (30-R: 10.2%, 90-R: 10.8%), postoperative infection (30-R: 13.7%, 90-R: 6.5%), and genitourinary complication (30-R: 3.9%, 90-R: 4.1%). On multivariate regression analysis, surgery type, age, hypertension, and renal failure were independently associated with 30-day readmission; rheumatoid arthritis/collagen vascular diseases, and coagulopathy were independently associated with 90-day readmission.

CONCLUSION

In this study, we demonstrate several patient-level factors independently associated with unplanned hospital readmissions after surgical treatment intervention for spine metastases. Furthermore, we find that the most common reasons for readmission are sepsis, postoperative infection, and genitourinary complications.Level of Evidence: 3.

Surgical Stabilization for Patients with Mechanical Back Pain Secondary to Metastatic Spinal Disease is Associated with Improved Objective Mobility Metrics: Preliminary Analysis in a Cohort of 26 Patients

OBJECTIVES

To investigate the effect of surgical stabilization for patients with metastatic spinal disease on objective mobility metrics.

METHODS

A retrospective chart review identified patients who had mechanical back pain from metastatic spinal disease and underwent spinal stabilization during 2017. Mobility metrics, the Activity Measure for Post-Acute Care (AM-PAC) inpatient mobility short form (IMSF) and the Johns Hopkins Highest Level of Mobility (JH-HLM), were reviewed.

RESULTS

A total of 26 patients were included in the analysis with median hospital stay of 8 days. Preoperative JH-HLM scores were available for 17 patients with a mean score of 5.4, increasing to mean score of 6.6 at last follow-up (P = 0.036). Preoperative AM-PAC IMSF scores were available for 14 patients with a mean score of 19.4, decreasing slightly to a mean score of 18.7 at last follow-up (P = 0.367). Last follow-up with mobility metrics occurred a median of 6.5 days postoperatively (range: 3-66 days). Multivariable analysis showed that American Spinal Injury Association and Karnofsky Performance Status scores were significantly associated with both JH-HLM and AM-PAC mobility scores at last follow-up. A higher JH-HLM or AM-PAC score was significantly associated with direct home discharge and a higher AM-PAC score was associated with shorter hospital stay.

CONCLUSIONS

Surgical stabilization for patients with mechanical back pain secondary to metastatic spinal disease might lead to an objective improvement in JH-HLM score. JH-HLM and AM-PAC scores may be correlated with length of hospital stay and discharge disposition. Future studies are encouraged to further characterize the role of these mobility metrics in the management plan of these patients.

Cost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors

OBJECTIVE

The aim of this study was to compare complication rates, length of stay (LOS), and hospital costs after spine surgery for bony spine tumors and intradural spinal neoplasms.

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult inpatients who underwent surgical intervention for a primary intradural spinal tumor or primary/metastatic bony spine tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis/procedural coding systems. Patient demographics, comorbidities, intraoperative variables, complications, LOS, discharge disposition, and total cost of hospitalization were assessed. Backward stepwise multivariable logistic regression analyses were used to identify independent predictors of perioperative complication, extended LOS (≥75th percentile), and increased cost (≥75th percentile).

RESULTS

A total of 9855 adult patients were included in the study; 3850 (39.1%) were identified as having a primary intradural spinal tumor and 6005 (60.9%) had a primary or metastatic bony spine tumor. Those treated for bony tumors had more comorbidities (≥3, 67.8% vs. 29.2%) and more commonly experienced ≥1 complications (29.9% vs. 7.9%). Multivariate analyses also showed those in the bony spine cohort had a higher odds of experiencing ≥1 complications (odds ratio [OR], 4.26; 95% confidence interval [CI], 3.04-5.97; P < 0.001), extended LOS (OR, 2.44; 95% CI, 1.75-3.38; P < 0.001), and increased cost (OR, 5.32; 95% CI, 3.67-7.71; P < 0.001).

CONCLUSIONS

Relative to patients being treated for primary intradural tumors, those undergoing spine surgery for bony spine tumors experience significantly higher risk for perioperative complications, extended LOS, and increased cost of hospital admission. Further identification of patient and treatment characteristics that may optimize management of spine oncology may reduce adverse outcomes, improve patient care, and reduce health care resources.

Health related quality of life outcomes following surgery and/or radiation for patients with potentially unstable spinal metastases

BACKGROUND

Currently there is no prospective pain and health related quality of life (HRQOL) data of patients with potentially unstable spinal metastases who were treated with surgery ± radiation or radiation alone.

METHODS

An international prospective cohort multicenter study of patients with potentially unstable spinal metastases, defined by a SINS score 7 to 12, treated with surgery ± radiation or radiotherapy alone was conducted. HRQOL was evaluated with the numeric rating scale (NRS) pain score, the SOSGOQ2.0, the SF-36, and the EQ-5D at baseline and 6, 12, 26, and 52 weeks after treatment.

RESULTS

A total of 136 patients were treated with surgery ± radiotherapy and 84 with radiotherapy alone. At baseline, surgically treated patients were more likely to have mechanical pain, a lytic lesion, a greater median Spinal Instability Neoplastic score, vertebral compression fracture, lower performance status, HRQOL, and pain scores. From baseline to 12 weeks post-treatment, surgically treated patients experienced a 3.0-point decrease in NRS pain score (95% CI -4.1 to -1.9, p<.001), and a 12.7-point increase in SOSGOQ2.0 score (95% CI 6.3-19.1, p<.001). Patients treated with radiotherapy alone experienced a 1.4-point decrease in the NRS pain score (95% CI -2.9 to 0.0, p=.046) and a 6.2-point increase in SOSGOQ2.0 score (95% CI -2.0 to 14.5, p=.331). Beyond 12 weeks, significant improvements in pain and HRQOL metrics were maintained up to 52-weeks follow-up in the surgical cohort, as compared with no significant changes in the radiotherapy alone cohort.

CONCLUSIONS

Patients treated with surgery demonstrated clinically and statistically significant improvements in pain and HRQOL up to 1-year postsurgery. Treatment with radiotherapy alone resulted in improved pain scores, but these were not sustained beyond 3 months and HRQOL outcomes demonstrated nonsignificant changes over time. Within the SINS potentially unstable group, distinct clinical profiles were observed in patients treated with surgery or radiotherapy alone.

A Novel Clinical Scoring System for Perioperative Morbidity in Metastatic Spinal Tumor Surgery: The Spine Oncology Morbidity Assessment Score

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate a scoring system to predict morbidity for patients undergoing metastatic spinal tumor surgery (MSTS).

SUMMARY OF BACKGROUND DATA

Multiple scoring systems exist to predict survival for patients with spinal metastasis. The potential benefits and risks of surgery need to be evaluated for patients with disseminated cancer and limited life expectancy. Few scoring systems exist to predict perioperative morbidity after MSTS.

METHODS

We reviewed records of patients who underwent MSTS at our institution between 2013 and 2019. All perioperative complications occurring within 30 days were recorded. A clinical scoring system consisting of five variables (age ≥ 70 yr, hypoalbuminemia, poor preoperative functional status [Karnofsky ≤ 40], Frankel Grade A-C, and multilevel disease ≥2 continuous vertebral bodies) was evaluated as a predictive tool for morbidity; every parameter was assigned a value of 0 if absent or 1 if present (total possible score = 5). The effect of the scoring system on morbidity was evaluated using stepwise multiple logistic regression. Model accuracy was calculated by receiver operating characteristic analysis.

RESULTS

One hundred and five patients were identified, with a male prevalence of 58.1% and average age at surgery of 61 years. The overall 30-day complication rate was 36.2%. The perioperative morbidity was 4.6%, 30.0%, 53.9%, and 64.7% for patients with scores of 0, 1, 2, and ≥3 points, respectively (P < 0.001). On multiple logistic regression analysis controlling for covariates not present in the model, the scoring system was significantly associated with 30-day morbidity (OR 3.11; 95% CI, 1.72-5.59; P < 0.001). The model's accuracy was estimated at 0.75.

CONCLUSION

Our proposed model was found to accurately predict perioperative morbidity after MSTS. The Spine Oncology Morbidity Assessment (SOMA) score may prove useful for risk stratification and possibly decision-making, though further validation is needed.Level of Evidence: 4.

Feasibility of salvage decompressive surgery for pending paralysis due to metastatic spinal cord compression

OBJECTIVE

Metastatic spinal cord compression (MSCC) is a frequent phenomenon in cancer disease, often leading to severe neurological deficits. Especially in patients with complete motor paralysis, regaining the ability to walk is an important treatment goal. Our study, therefore, aimed to assess the neurological outcome of patients with MSCC and complete motor paralysis after decompressive surgery.

METHODS

Patients with MSCC and complete motor paralysis, surgically treated by decompressive surgery between 2004-2014 at a single institution were retrospectively analyzed. Clinical patient data were collected from medical records. To assess the neurological outcome, Frankel grade (FG) at admission and discharge were compared. Statistical analysis was performed to identify factors associated with an ambulatory status after surgery.

RESULTS

Twenty-eight patients were included in this study. The majority of metastases (57 %) were located in the thoracic spine and 75 % showed extraspinal tumor spread. The median interval between loss of ambulation and surgery was 35 h (IQR: 29-70). Posterior circumferential decompression without stabilization was performed in all cases within 24 h of admission. Neurological function improved in 17 patients (63 %) and seven (26 %) even regained the ability to walk following surgery. The rate of complications was low (7%). In statistical analysis, only the Karnofsky Performance Index (KPI) displayed a significant predictive value for an ambulatory status at discharge.

CONCLUSIONS

Our findings indicate that severely affected MSCC patients with complete motor paralysis might benefit from decompressive surgery even when the loss of ambulation occurred more than 24 h ago.

[Surgical treatment results of metastatic spine disease with using minimally invasive technologies, including 3D video endoscopic technologies]

THE AIM OF THE STUDY

Was to evaluate the results of surgical treatment of patients with metastatic lesions of the spine using 3-D video endoscopic technologies.

MATERIAL AND METHODS

We analysed the results of surgical treatment of 33 patients with metastatic lesions of the thoracic spine using a 3D video-assisted thoracoscopic intervention that was performed from November 2017 to December 2019. When examining patients, the following were used: X-ray of the spine, spiral computed tomography (CT), magnetic resonance imaging (MRI), as well as the SINS, Bilsky, Karnovsky, Tokuhashi, Frankel, SF-36 and VAS scales.

RESULTS

The actual life expectancy of the patients completely coincided with the predicted one according to the Tokuhashi scale. Regression of neurological disorders in the early postoperative period (before discharge from the hospital) was observed in 6% of patients (complete in 3%, partial in 3%). When evaluating the results of treatment 12 months after surgery, regression of neurological symptoms was observed in 19% of patients. At the same time, complete regression of neurological disorders occurred in 10%, partial in 9% of patients. When assessing the quality of life on the SF-36 scale, improvement was observed according to the most of the criteria. Also, in the postoperative period, there was a persistent decrease in the intensity of pain syndrome according to VAS compared with the preoperative level.

CONCLUSION

The use of 3-D video endoscopic technologies in the surgical treatment of patients with metastatic lesions of the spine made it possible to improve the quality of life of patients and reduce the number of complications.

Prospective cohort study of surgical outcome for spinal metastases in patients aged 70 years or older

AIMS

With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values.

METHODS

We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected.

RESULTS

In total, 65 patients were aged < 70 years (mean 59.6 years; 32 to 69) and 36 patients were aged ≥ 70 years (mean 75.9 years; 70 to 90). In both groups, the PS improved from PS3 to PS1 by spine surgery, the mean BI improved from < 60 to > 80 points, and the mean EQ-5D score improved from 0.0 to > 0.7 points. However, no significant differences were found in the improvement rates and values of the PS, BI, and EQ-5D score at any time points between the two groups. The PS, BI, and EQ-5D score improved throughout the follow-up period in approximately 90% of patients in each group. However, the improved PS, BI, and EQ-5D scores subsequently deteriorated in some patients, and the redeterioration rate of the EQ-5D was significantly higher in patients aged ≥ 70 than < 70 years (p = 0.027).

CONCLUSION

Palliative surgery for spinal metastases improved the PS, activities of daily living, and quality of life, regardless of age. However, clinicians should be aware of the higher risk of redeterioration of the quality of life in advanced-age patients. Cite this article: Bone Joint J 2020;102-B(12):1709-1716.

Surgical complications and re-operation rates in spinal metastases surgery: a systematic review

OBJECTIVE

The goal of this study was to review the incidence of complications and unplanned re-operations after surgery for metastatic spinal tumors.

BACKGROUND

The spinal column is the most common osseous site for metastatic spread. The goals of the treatment of spinal metastases are largely palliative. The surgical aims include establishing a diagnosis, providing stability, relieving neurological compression and deterioration, decreasing pain and increasing patient independence. Patients with spinal metastases who undergo surgery are considered high risk, with higher morbidity and mortality rates.

MATERIALS AND METHODS

A systematic review was undertaken; PubMed and Embase databases were searched between (2010-2020) for relevant publications in English language with the following search items: metastasis OR metastases AND spine AND surgery AND complications OR revision. Using a standard PRISMA template, 2293 articles were identified. Full-text articles of interest were assessed for inclusion criteria of greater than 30 patients.

RESULTS

A final number of 19 articles fully met the search criteria. Four were level II evidence, and the remaining were level III/IV. Surgical site infection 6.5% (135/2088) was reported as the main complication following surgery for spinal metastases followed by neurological deterioration 3.3% (53/1595) and instrumentation failure 2.0% (30/1501). Re-operation rate was 8.3% (54/651), with SSI (27.8%) being the most common reason for revision surgery.

CONCLUSION

Patients with spinal metastases frequently present with complex therapeutic challenges requiring multidisciplinary team assessment. Surgical site infection (6.5%) was the main reason for a re-operation in patients undergoing surgery for spinal metastases.

A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.

Surgery for spinal metastatic tumors: Prognostication systems in clinical practice (Review)

The management of spinal metastatic tumors is a matter of increasing clinical importance, as 20-40% of cancer patients have evidence of vertebral metastatic disease at the time of their passing and up to 20% develop neurological symptoms due to epidural spinal cord compression. The treatment of patients with spinal metastases is challenging, albeit palliative, and it requires a multidisciplinary approach. Accurate prediction of life expectancy of patients with cancer is of paramount importance for therapeutic strategy. Prognostication scoring systems were developed to aid clinicians to follow a more objective, safe and evidence-based approach with therapy selection and surgical intervention indications. In this context, the aim of the present review was to briefly discuss the evolution of scoring systems since their introduction in the early 90s until today, their advantages and shortcomings, and the future requirements for personalized scoring in the era of modern oncology.

How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database

BACKGROUND

The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database.

METHODS

The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed.

RESULTS

A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%.

CONCLUSION

We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.

Impact of decompressive laminectomy on the functional outcome of patients with metastatic spinal cord compression and neurological impairment

Metastatic spinal cord compression (MSCC) is a frequent phenomenon in advanced tumor diseases with often severe neurological impairments. Affected patients are often treated by decompressive laminectomy. To assess the impact of this procedure on Karnofsky Performance Index (KPI) and Frankel Grade (FG) at discharge, a single center retrospective cohort study of neurologically impaired MSCC-patients treated with decompressive laminectomy between 2004 and 2014 was performed. 101 patients (27 female/74 male; age 66.1 ± 11.5 years) were identified. Prostate was the most common primary tumor site (40%) and progressive disease was present in 74%. At admission, 80% of patients were non-ambulatory (FG A–C). Imaging revealed prevalently thoracic MSCC (78%). Emergency surgery (< 24 h) was performed in 71% and rates of complications and revision surgery were 6% and 4%, respectively. At discharge, FG had improved in 61% of cases, and 51% of patients had regained ambulation. Univariate predictors for not regaining the ability to walk were bowl dysfunction (p = 0.0015), KPI < 50% (p = 0.048) and FG < C (p = 0.001) prior to surgery. In conclusion, decompressive laminectomy showed beneficial effects on the functional outcome at discharge. A good neurological status prior to surgery was key predictor for a good functional outcome.

Surgical Decompression of High-Grade Spinal Cord Compression from Hormone Refractory Metastatic Prostate Cancer

BACKGROUND

Spine and nonspine skeletal metastases occur in more than 80% of patients with prostate cancer.

OBJECTIVE

To examine the characteristics of the patient population undergoing surgery for the treatment of prostate cancer metastatic to the spine.

METHODS

A retrospective chart review was performed on all patients treated at our institution from June 1993 to August 2014 for surgical management of metastatic spine disease from prostate cancer.

RESULTS

During the study period, 139 patients with 157 surgical lesions underwent surgery for metastatic spine disease. Decompression for high-grade epidural spinal cord compression was required for 126 patients with 143 lesions. Preoperatively, 69% had a motor deficit and 21% were nonambulatory, with 32% due to motor weakness. At surgery, 87% of patients had hormone-refractory prostate cancer (HRPC) and 61% failed prior radiation. Median overall survival for HRPC patients was 6.6 mo (95% confidence interval [CI]: 5.6-8.6) while the median overall survival for hormone-sensitive patients was 16.3 mo (95% CI: 4.0-26.6).

CONCLUSION

The majority of patients undergoing surgery for prostate cancer metastases to the spine were refractory to hormone therapy, indicating that patients with hormone-sensitive prostate cancer are unlikely to develop symptomatic spinal cord compression or spinal instability. A significant number of HRPC patients presented with neurological deficits attributable to spinal cord compression. Vigilant monitoring for the development of signs and symptoms of epidural spinal cord compression and spinal instability in hormone-refractory patients is recommended. Surgical decision making may be affected by the much shorter postoperative survival for HRPC patients as compared to patients with hormone-sensitive cancer.

Functional Outcomes of Surgical Management for Spinal Epidural Masses in an Egyptian Tertiary Hospital

BACKGROUND:

The spinal epidural space, covering the dural sac, is located along the posterior longitudinal ligament anteriorly, the ligamentum flavum and the periosteum of laminae posteriorly, and the pedicles of the spinal column by the intervertebral foramina containing their neural elements laterally. It could be affected variably by different types of diseases, either as primary lesions or as an extension from a disease process in the nearby tissues and organs.

AIM:

We aimed to present clinically and surgically patients with spinal epidural masses operated in the Neurosurgery Department of Cairo University Hospitals, Cairo, Egypt, along a time interval of one year.

METHODS:

In this prospective cohort study, we analysed motor deficits, sensory deficits, and bowel and bladder dysfunction. We have performed decompressive laminectomy on 19 patients with spinal epidural masses together with mass excision as long as the tumour was accessible, with or without fixation.

RESULTS:

All patients were radiologically assessed by MRI over the affected side of the spine. D10 was the commonest site in our study to be affected in 10 cases of our participants (23%), followed by D5, D7, and D12 each of them was affected in 6 cases (14%), in another word spinal segments by order of frequency to be affected were dorsal followed by lumbar spine. All patients included in this study (100%) showed an obvious improvement as regard pain and tenderness.

CONCLUSION:

Surgical interventions have improved the quality of life for our patients with spinal epidural masses.

Outcomes of surgical treatments of spinal metastases: a prospective study

BACKGROUND

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.

OBJECTIVE

To analyse the outcomes of surgical treatments of spinal metastases.

METHODS

Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.

RESULTS

A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.

CONCLUSION

Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

The purpose of this study is to compare and validate several preoperative scores for predicting outcomes following spine tumor resection.

SUMMARY OF BACKGROUND DATA

Preoperative risk assessment for patients undergoing spinal tumor resection remains challenging. At present, few risk assessment tools have been validated in this high-risk population.

METHODS

The 2008 to 2014 National Surgical Quality Improvement database was used to identify all patients undergoing surgical resection of spinal tumors, stratified as extradural, intradural extramedullary, and intramedullary based on CPT codes. American Society of Anesthesiologists (ASA) score, modified Charlson Comorbidity Index (CCI), and modified Frailty Index (mFI) were computed. A binary logistic regression model was used to explore the relationship between these variables and postoperative outcomes, including mortality, major and minor adverse events, and hospital length of stay (LOS). Other significant variables such as demographics, operative time, and tumor location were controlled for in each model.

RESULTS

Two thousand one hundred seventy patients met the inclusion criteria. Higher CCI scores were independent predictors of mortality (OR = 1.24, 95% CI: 1.14-1.36, P < 0.001), major adverse events (OR = 1.07, 95% CI: 1.01-1.31, P = 0.018), minor adverse events (OR = 1.15, 95% CI: 1.10-1.20, P < 0.001), and prolonged LOS (OR = 1.14, 95% CI: 1.09-1.19, P < 0.001). Patients' mFI scores were significantly associated with mortality and LOS, but not major or minor adverse events. ASA scores were not associated with any outcome metric when controlling for other variables.

CONCLUSION

The CCI demonstrated superior predictive capacity compared with mFI and ASA scores and may be valuable as a preoperative risk assessment tool for patients undergoing surgical resection of spinal tumors. The validation of assessment scores is important for preoperative risk stratification and improving outcomes in this high-risk group.

LEVEL OF EVIDENCE

3.

Timing of Prophylactic Anticoagulation and Its Effect on Thromboembolic Events After Surgery for Metastatic Tumors of the Spine

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the effect of timing of initiation of prophylactic anticoagulation (AC) on the incidence of venous thromboembolism (VTE) after surgery for metastatic tumors of the spine.

SUMMARY OF BACKGROUND DATA

VTE is a known complication in patients undergoing surgery for metastatic spine disease. However, there is limited data on the use of prophylactic AC in this population and its impact on the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as the risk of epidural hematoma.

METHODS

A retrospective review of our institutional neurosurgical spine database for the years 2012 through 2018 was performed. Patients who underwent surgery for metastatic tumors were identified. The development of VTE within 30 days was examined, as well as the occurrence of epidural hematoma. The incidence of VTE was compared between patients receiving "early" (within postoperative days 1-3) and "delayed" prophylactic AC (on or after postoperative day 4).

RESULTS

Sixty-five consecutive patients were identified (mean age 57, 62% male). The overall rate of VTE was 16.9%-all of whom had DVTs with a 3.1% rate of nonfatal PE (two patients also developed PE). From the overall cohort, 36 of 65 (56%) received prophylactic AC in addition to mechanical prophylaxis-22 in the early group (61.1%) and 14 in the delayed group (38.9%). The risk of VTE was 9.1% in the early group and 35.7% in the delayed group (26.6% absolute risk reduction; P = 0.049); there was one case of epidural hematoma (1.5%). On multivariate analysis, delayed prophylactic AC was found to significantly increase the odds of VTE development (OR 6.43; 95% CI, 1.01-41.2; P = 0.049).

CONCLUSION

The findings of this study suggest that administration of prophylactic AC between days 1 and 3 after surgery for metastatic tumors of the spine may significantly reduce the risk of postoperative thromboembolic events.

LEVEL OF EVIDENCE

4.

Hypoalbuminemia as an Independent Risk Factor for Perioperative Complications Following Surgical Decompression of Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Malnutrition has been shown to be a risk factor for poor perioperative outcomes in multiple surgical subspecialties, but few studies have specifically investigated the effect of hypoalbuminemia in patients undergoing operative treatment of metastatic spinal tumors. The aim of this study was to assess the role of hypoalbuminemia as an independent risk factor for 30-day perioperative mortality and morbidity after surgical decompression of metastatic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.

METHODS

We identified 1498 adult patients in the ACS-NSQIP database who underwent laminectomy and excision of metastatic extradural spinal tumors. Patients were categorized into normoalbuminemic and hypoalbuminemic (ie, albumin level <3.5 g/dL) groups. Univariate and multivariate regression analyses were performed to examine the association between preoperative hypoalbuminemia and 30-day perioperative mortality and morbidity. Subgroup analysis was performed in the hypoalbuminemic group to assess the dose-dependent effect of albumin depletion.

RESULTS

Hypoalbuminemia was associated with increased risk of perioperative mortality, any complication, sepsis, intra- or postoperative transfusion, prolonged hospitalization, and non-home discharge. However, albumin depletion was also associated with decreased risk of readmission. There was an albumin level-dependent effect of increasing mortality and complication rates with worsening albumin depletion.

CONCLUSIONS

Hypoalbuminemia is an independent risk factor for perioperative mortality and morbidity following surgical decompression of metastatic spinal tumors with a dose-dependent effect on mortality and complication rates. Therefore, it is important to address malnutrition and optimize nutritional status prior to surgery.

Outcome of Surgical Treatment for Spinal Cord Compression in Patients With Hematological Malignancy

Background

We investigated the outcome of surgical treatment of patients with radiosensitive hematological malignancies presenting with spinal cord compression.

Methods

Retrospective review of 50 patients who had treatment between 1993 and 2012.

Results

The neurological outcome was favorable in 35 patients, stable in 12, whereas 3 patients deteriorated. Decompression within 48 hours from referral was associated with a superior neurological recovery (P = .001). Complications were noted in 11 patients, and 6 of these underwent secondary surgery. Early (30-day) mortality was 8%. Radiotherapy was associated with increased incidence of complications (χ² = 0.009). Patients who had low blood hemoglobin preoperatively as well as those who remained totally bedridden postoperatively had an inferior overall survival rate (P < .001).

Conclusion

Patients with cord compression from hematological malignancy benefit from early surgical decompression. There is an inherent high risk for complications, which increases further if radiotherapy is given. Patients failing to ambulate after surgery have a poor prognosis.

Minimally Invasive Surgery without Decompression for Hepatocellular Carcinoma Spinal Metastasis with Epidural Spinal Cord Compression Grade 2

Objective

There is a lack of knowledge regarding whether decompression is necessary in treating patients with epidural spinal cord compression (ESCC) grade 2. The purpose of this study was to compare the outcomes of minimally invasive surgery (MIS) without decompression and conventional open surgery (palliative laminectomy) for patients with hepatocellular carcinoma (HCC) spinal metastasis of ESCC grade 2.

Methods

Patients with HCC spinal metastasis requiring surgery were retrospectively reviewed. Patients with ESCC grade 2, medically intractable mechanical back pain, a Nurick grade better than 3, 3–6 months of life expectancy, Tomita score ≥5, and Spinal Instability Neoplastic Score ≥7 were included. Patients with neurological deficits, other systemic illnesses and less than 1 month of life expectancy were excluded. Thirty patients were included in the study, including 17 in the open surgery group (until 2008) and 13 in the MIS group (since 2009).

Results

The MIS group had a significantly shorter operative time (94.2±48.2 minutes vs. 162.9±52.3 minutes, p=0.001), less blood loss (140.0±182.9 mL vs. 1534.4±1484.2 mL, p=0.002), and less post-operative intensive care unit transfer (one patient vs. eight patients, p=0.042) than the open surgery group. The visual analogue scale for back pain at 3 months post-operation was significantly improved in the MIS group than in the open surgery group (3.0±1.2 vs. 4.3±1.2, p=0.042). The MIS group had longer ambulation time (183±33 days vs. 166±36 days) and survival time (216±38 days vs. 204±43 days) than the open surgery group without significant difference (p=0.814 and 0.959, respectively).

Conclusion

MIS without decompression would be a good choice for patients with HCC spinal metastasis of ESCC grade 2, especially those with limited prognosis, mechanical instability and no neurologic deficit.

Clinical outcomes and significant factors in the survival rate after decompression surgery for patients who were non-ambulatory due to spinal metastases

BACKGROUND

The development of effective chemotherapy regimens and molecular targeting agents are improving the overall survival rates in patients with cancer. However, patients who are non-ambulatory due to metastatic epidural spinal cord compression (MESCC) may be assessed as unable to tolerate chemotherapy secondary to poor performance status. This means that the ambulatory status of patients with cancer might be significant for survival time.

METHODS

We investigated the functional outcomes and factors influencing overall survival in 31 patients who were non-ambulatory due to MESCC and underwent decompression surgery. The functional outcome was determined by the Frankel grading system.

RESULT

Twenty-one patients (68%) improved by at least 1 Frankel grade; 17 patients (55%) became ambulatory postoperatively. Most of postoperatively ambulatory patients could undergo postoperative chemotherapy (14/17, 82%). On the other hand, only a few postoperatively non-ambulatory patients could undergo postoperative chemotherapy (2/15, 13%). We observed a complication rate of 35.5% with specific complications including wound infection, pneumonia, and deep vein thrombosis/pulmonary embolus. The median survival duration was 7.0 months. Factors that significantly affected the overall survival in univariate analyses were revised Tokuhashi score (RTS) ≥ 4, postoperative chemotherapy, ambulatory status, and complications (RTS ≥ 4, P < 0.05; postoperative chemotherapy, P < 0.001; ambulatory status, P < 0.001; complications, P < 0.01).

CONCLUSIONS

Decompression surgery for patients who are non-ambulatory due to MESCC directly contributes to functional outcomes and may indirectly contribute to overall survival. If non-ambulatory patients who are assessed as unable to tolerate chemotherapy due to poor performance status regain the ability to walk by decompression surgery, they will have a chance to receive postoperative chemotherapy, thereby increasing their chances of prolonging survival. However, postoperative complications may shorten their survival; therefore, we should carefully consider the surgical indications. RTS is useful for judging the surgical indication.

Complications and reoperations after surgery for 647 patients with spine metastatic disease

BACKGROUND CONTEXT

Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival.

PURPOSE

We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers.

OUTCOME MEASURES

Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death.

METHODS

We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival.

RESULTS

From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49-0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00-2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97-2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02-2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06-5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07-2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17-1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09-1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery.

CONCLUSIONS

Three or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.

Clinical management of spinal metastases-The Dutch national guideline

This article is a summary of the revised Dutch multidisciplinary evidence-based guideline 'Spinal metastases' (English translation available at: https://www.oncoline.nl/spinal-metastases) that was published at the end of 2015. This summary provides an easy-to-use overview for physicians to use in their daily practice.

Surgical results and clinical risks of postoperative complications in patients with painful malignant spinal cord compression after decompressive surgery

Introduction

This study aims to analyze clinical outcome in patients with painful malignant spinal cord compression due to advanced cancers after the decompressive surgery and identify risk factors for postoperative complications in these patients. Furthermore, we created a scoring model to predict the risk of postoperative complications based on identified significant risk factors.

Methods

We retrospectively analyzed survival outcomes, pain outcomes, and postoperative complications of patients with painful malignant spinal cord compression who were surgically treated in our department. Identification of risk factors for postoperative complications was also performed, and significant factors according to the multiple logistic regression models were included in the scoring model.

Results

As a result, 105 patients were enrolled. The overall median survival time was 9.1 months (95% CI, 7.1–11.4 months). The mean worst pain score was 8.0 in a 24-hour period before surgery, while it decreased to 6.0, 5.0, 3.5, 3.3, and 3.6 (all P<0.01, when compared with baseline date) at 1 week, 1 month, 3, 6, and 12 months after surgery, respectively. Similar decreases were also observed in the average pain and the pain interference. Thirty-one complications occurred within 4 weeks after operation in 26 patients (24.8%, 26/105). Based on multiple logistic regression models, age (P=0.03), Karnofsky performance status (P<0.01), and Charlson Comorbidity Index (P=0.04) were significantly associated with postoperative complications and were included in the scoring model. Three risk groups were created based on the complication rates of each scoring points. The corresponding postoperative complication rates of the three groups were 7.7% in group A (0–3 points), 26.7% in group B (4–6 points), and 60.9% in group C (7–10 points), respectively (OR, 4.32, 95% CI: 2.24–8.31, P<0.01).

Conclusion

Decompressive surgery for painful malignant spinal cord compression was found to be useful for pain control with a tolerable rate of complications. We created a scoring model to predict the risk of postoperative complications in patients with painful malignant spinal cord compression after surgery. This scoring model may guide doctors to choose the appropriate care strategies to realize better pain management.

Surgical site infection in spinal metastasis: incidence and risk factors

BACKGROUND

Surgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality.

OBJECTIVE

This study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors.

STUDY DESIGN

This is a retrospective analysis of a prospectively collected data.

METHODS

Preoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (<90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p<.05 as significance threshold.

RESULTS

A total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI.

CONCLUSION

This paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

Management - spinal metastases

Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.

The Impact of Metastatic Spinal Tumor Location on 30-Day Perioperative Mortality and Morbidity After Surgical Decompression

STUDY DESIGN

A retrospective cohort study from 2011 to 2014 was performed using the American College of Surgeons National Surgical Quality Improvement Program database.

OBJECTIVE

The purpose of this study was to assess the impact of tumor location in the cervical, thoracic, or lumbosacral spine on 30-day perioperative mortality and morbidity after surgical decompression of metastatic extradural spinal tumors.

SUMMARY OF BACKGROUND DATA

Operative treatment of metastatic spinal tumors involves extensive procedures that are associated with significant complication rates and healthcare costs. Past studies have examined various risk factors for poor clinical outcomes after surgical decompression procedures for spinal tumors, but few studies have specifically investigated the impact of tumor location on perioperative mortality and morbidity.

METHODS

We identified 2238 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent laminectomy for excision of metastatic extradural tumors in the cervical, thoracic, or lumbosacral spine. Baseline patient characteristics were collected from the database. Univariate and multivariate regression analyses were performed to examine the association between spinal tumor location and 30-day perioperative mortality and morbidity.

RESULTS

On univariate analysis, cervical spinal tumors were associated with the highest rate of pulmonary complications. Multivariate regression analysis demonstrated that cervical spinal tumors had the highest odds of multiple perioperative complications. However, thoracic spinal tumors were associated with the highest risk of intra- or postoperative blood transfusion. In contrast, patients with metastatic tumors in the lumbosacral spine had lower odds of perioperative mortality, pulmonary complications, and sepsis.

CONCLUSION

Tumor location is an independent risk factor for perioperative mortality and morbidity after surgical decompression of metastatic spinal tumors. The addition of tumor location to existing prognostic scoring systems may help to improve their predictive accuracy.

LEVEL OF EVIDENCE

3.

Thirty-day complication and readmission rates associated with resection of metastatic spinal tumors: a single institutional experience

Background

This study aims to assess 30-day complication and unplanned readmission rates associated with resection of metastatic spinal tumors.

Methods

Medical records were reviewed for 135 adults who underwent elective resection of a spinal cord tumor. Patient demographics, comorbidities, and tumor characteristics were collected. Tumor pathology was analyzed and diagnosed by a pathologist. The primary outcomes were intra- and 30-day post-operative complication and readmission rates.

Results

Of the 135 spinal tumor resections, 30 (22.2%) cases were metastatic. The most common tumor pathology was bone (13.3%) and the most common locations were thoracic (45.2%), and cervical (32.7%). Most patients had an open surgery (96.7%), with a mean laminectomy/laminoplasty level of 1.9±1.5 and mean operative time of 328.4±658.0 min. There was a 3.3% incidence rate of intraoperative durotomies, with no spinal cord or nerve root injuries. Post-operatively, 44.8% of patients were transferred to the intensive care unit (ICU). The most common post-operative complications were weakness (20.0%), new sensory deficits (16.7%), and hypotension (13.3%). The mean length of stay was 8.8±7.6 days, with the majority of patients discharged home (96.7%). The 30-day readmission rate was 9.7%, with the most common 30-day complications being uncontrolled pain (16.7%), sensory-motor deficits (13.3%), and fever (10.0%).

Conclusions

Our study suggests that weakness, sensory deficits, and uncontrolled pain are the most common complications after resection of spinal metastases, with a relatively high associated 30-day readmission rate. Further studies are necessary to corroborate our findings and identify strategies to reduce complication and readmission rates after resection of spinal metastases.