The revised Tokuhashi score; analysis of parameters and assessment of its accuracy in determining survival in patients afflicted with spinal metastasis

The Impact of Adjunct Medical Therapy on Survival after Spine Metastasis: A Systematic Review and Pooled Data Analysis

Targeted therapy has greatly improved the outlook for patients with spinal metastatic cancers. Scoring systems like the Tokuhashi or Tomita scores are commonly used to predict prognosis and inform surgical decisions, but they are outdated and fail to consider recent advancements. We aimed to investigate the current state of the literature and treatment options pertaining to advancements in targeted therapy compared to other forms of medical management for metastatic spinal tumors. This study represents the first comprehensive systematic review that encompasses the most common primary cancers that metastasize to the spine and evaluates the median overall survival (mOS) across five different medical treatment modalities as well as surgical intervention. Additionally, our study analyzes the tumor receptor status in conjunction with these treatments. A PubMed search was conducted, and according to the PRISMA guidelines, 28 articles out of 1834 met the inclusion criteria. The pooled data analysis highlighted the superior efficacy of targeted therapy, evidenced by a significant improvement in the mOS and lower hazard ratios in patients with lung and breast cancers who received targeted therapy compared to those who did not. Our study provides valuable insights into the recent advancements in the medical management of metastatic spinal tumors. Future indications include incorporating this literature into personalized treatment approaches for metastatic spinal tumors.

A novel prognostic scoring system combining the revised Tokuhashi score and the New England spinal metastasis score for preoperative evaluation of spinal metastases

Purpose

Numerous scoring systems have been developed in order to determine the prognosis of spinal metastases. Predicting as accurately as possible the life expectancy of patients with spinal metastatic disease is very important, as it's the decisive factor in selecting the optimal treatment for the patient. The Revised Tokuhashi score (RTS) and the New England Spinal Metastasis score (NESMS) are popular scoring systems used to determine the optimal treatment modality. However, they sometimes provide conflicting results. We propose a novel prognostic scoring system, which combines the RTS and NESMS scores in order to predict with greater accuracy the prognosis.

Methods

We retrospectively reviewed the data of 64 patients with spinal metastasis enrolled between 2012 and 2021 in the Department of Orthopedic Surgery-Spine, Hôpital Maisonneuve-Rosemont, Montréal, Que. The new score per patient was calculated as a combination of the RTS of each patient and the patient's corresponding NESMS. The new score was then compared to the actual patient survival period and divided into 3 categories: Low, Moderate and Good prognosis. We then compared the accuracy of our new score to RTS.

Results

In the Low Prognosis group, the reliability of predicting the prognosis was 51.9% in 27 patients. In the Moderate Prognosis group, the reliability of predicting the prognosis was 95.8% in 24 patients. In the Good Prognosis group, the reliability of predicting the prognosis was 100% in 13 patients. Our new score was found more accurate than RTS as the R2 parameter corresponding to the new score was significantly increased compared to the same parameter corresponding to the RTS score indicating a higher percentage of survival predictability for the new score as compared to the RTS score.

Conclusion

This study demonstrates that a new prognostic scoring system, which would combine the RTS and the NESMS, is promising in providing an improved accuracy for predicting the actual patient survival, especially for the moderate and good prognosis patients. An appropriate prospective investigation with a larger sample size should be conducted in order to further investigate the validity of this novel scoring system and its overall predictive value.

Can We Use Artificial Intelligence Cluster Analysis to Identify Patients with Metastatic Breast Cancer to the Spine at Highest Risk of Postoperative Adverse Events?

OBJECTIVE

Group patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes.

METHODS

A retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ2 test and one-way analysis of variance.

RESULTS

Five patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0 ± 0.8. Low function/irradiated (LOW + RADS) had preoperative radiation and the lowest Karnofsky scores (56.0 ± 10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0 ± 11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW + NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW + RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW + NEURO (P = 0.003).

CONCLUSIONS

Function at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention.

Development and Validation of a Prognostic Model for Overall Survival in Patients with Primary Pelvis and Spine Osteosarcoma: A Population-Based Study and External Validation

Background: Primary pelvis and spine osteosarcoma (PSOS) is a specific type of osteosarcoma that is difficult to treat and has a poor prognosis. In recent years, the research on osteosarcoma has been increasing, but there have been few studies on PSOS; in particular, there have been a lack of analyses with a large sample size. This study aimed to construct and validate a model to predict the overall survival (OS) of PSOS patients, as currently there are no tools available for assessing their prognosis. Methods: Data including demographic information, clinical characteristics, and follow-up information on patients with PSOS were collected from the Surveillance, Epidemiology, and End Results (SEER) database, as well as from the Spine Tumor Center of Changzheng Hospital. Variable selection was achieved through a backward procedure based on the Akaike Information Criterion (AIC). Prognostic factors were identified by univariate and multivariate Cox analysis. A nomogram was further constructed for the estimation of 1-, 3-, and 5-year OS. Calibration plots, the concordance index (C-index), and the receiver operating characteristic (ROC) were used to evaluate the prediction model. Results: In total, 83 PSOS patients and 90 PSOS patients were separately collected from the SEER database and Changzheng Hospital. In the SEER cohort, liver metastasis, lung metastasis, and chemotherapy were recognized as independent prognostic factors for OS (p < 0.05) and were incorporated to construct the initial nomogram. However, the initial nomogram showed poor predictive accuracy in internal and external validation. Then, we shifted our focus to the Changzheng data. Lung metastasis involving segments, Eastern Cooperative Oncology Group (ECOG) performance score, alkaline phosphatase (ALP) level, and en bloc resection were ultimately identified as independent prognostic factors for OS (p < 0.05) and were further incorporated to construct the current nomogram, of which the bias-corrected C-index was 0.834 (0.824–0.856). The areas under the ROC curves (AUCs) of the current nomogram regarding 1-, 3-, and 5-year OS probabilities were 0.93, 0.96, and 0.92, respectively. Conclusion: We have developed a predictive model with satisfactory performance and clinical practicability, enabling effective prediction of the OS of PSOS patients and aiding clinicians in decision-making.

Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm

STUDY DESIGN

Narrative Review. The spine remains the most common site for bony metastasis. It is estimated that up to 70% of cancer patients harbor secondary spinal disease. And up to 10% will develop a clinically significant lesion. The last two decades have seen a substantial leap forward in the advancements of the management of spinal metastases. What once was a death sentence is now a manageable, even potentially treatable condition. With marked advancements in the surgical treatment and post-operative radiotherapy, a standardized approach to stratify and manage these patients is both prudent and now feasible.

OBJECTIVES

This article looks to examine the best available evidence in the stratification and surgical management of patients with spinal metastases. So the aim of this review is to offer a standardized approach for surgical management and surgical planning of patients with spinal metastases.

Impact of Obesity on Perioperative Complications on Treatment of Spinal Metastases: A Multicenter Surveillance Study from the German Spine Registry (DWG-Register)

Background  The spine is a common location for the development of primary and metastatic tumors, spinal metastases being the most common tumor in the spine. Spinal surgery in obesity is challenging due to difficulties with anesthesia, intravenous access, positioning, and physical access during surgery. The objective was to investigate the effect of obesity on perioperative complications by discharge in patients undergoing surgery for spinal metastases.

Methods  Retrospective analysis of data from the DWG-register on patients undergoing surgery for metastatic disease in the spine from January 2012 to December 2016. Preoperative variables included obesity (≥ 30 kg/m ² ), age, gender, and smoking status. In addition, the influence of pre-existing medical comorbidity was determined, using the American Society of Anesthesiologists (ASA) score.

Results  In total, 528 decompressions with and without instrumentation undergoing tumor debulking, release of the neural structures, or tumor extirpation in metastatic disease of the spine were identified; 143 patients were obese (body mass index [BMI] ≥ 30 kg/m ² ), and 385 patients had a BMI less than 30 kg/m ² . The mean age in the group with BMI 30 kg/m ² or higher (group 1) was 67 years (56.6%). In the group with BMI less than 30 kg/m ² (group 2), the mean age was 64 years. Most of the patients had preoperatively an ASA score of 3 and 4 (patients with severe general disease). The likelihood of being obese in the logistic regression model seems to be protective by 47.5-fold for blood loss 500 mL or higher. Transfusions occurred in 321/528 (60.7%) patients (group 1, n  = 122 and group 2, n  = 299; p  = 0.04). A total of 19 vertebroplasties with percutaneous stabilization (minimally invasive spine [MIS]), 6 vertebroplasties, and 31 MIS alone were identified. The variables between these groups, with exception of preoperative status (ASA-score; p  = 0.02), remained nonsignificant.

Conclusion  Obese patients were predisposed to have blood loss more than 500 mL more often than nonobese patients undergoing surgery for spinal metastases but with perioperative blood transfusions, invasiveness, nor prolonged hospitalization. Early postoperative mobilization and a low threshold for perioperative venous thromboembolism (VTE) are important in obese patients to appropriately diagnose, treat complications, and minimize morbidity.

Ten Years After SINS: Role of Surgery and Radiotherapy in the Management of Patients With Vertebral Metastases

The objective of the different types of treatments for a spinal metastasis is to provide the best oncological and functional result with the least aggressive side effects. Initially created in 2010 to help clinicians in the management of vertebral metastases, the Spine Instability Neoplastic Score (SINS) has quickly found its place in the decision making and the treatment of patients with metastatic spinal disease. Here we conduct a review of the literature describing the different changes that occurred with the SINS score in the last ten years. After a brief presentation of the spinal metastases’ distribution, with or without spinal cord compression, we present the utility of SINS in the radiological diagnosis and extension of the disease, in addition to its limits, especially for scores ranging between 7 and 12. We take this opportunity to expose the latest advances in surgery and radiotherapy concerning spinal metastases, as well as in palliative care and pain control. We also discuss the reliability of SINS amongst radiologists, radiation oncologists, spine surgeons and spine surgery trainees. Finally, we will present the new SINS-derived predictive scores, biomarkers and artificial intelligence algorithms that allow a multidisciplinary approach for the management of spinal metastases.

Zoledronic Acid Versus Denosumab for Prevention of Spinal Cord Compression in Advanced Cancers With Spine Metastasis: A Meta-Analysis of Randomized Controlled Trials

STUDY DESIGN

Meta-analysis of randomized controlled trials (RCTs).

OBJECTIVES

The aim was to analyze the efficacy of zoledronic acid (ZA) versus denosumab in the prevention of spinal cord compression in patients with spine metastases from advanced cancers, by evaluating all available RCTs on this subject.

METHODS

A systematic search of electronic databases (PubMed and MEDLINE) was performed to identify all published RCTs comparing ZA with denosumab in prevention of spinal cord compressions in spine metastases. Risk of bias of the studies was assessed. The primary outcomes evaluated were spinal cord compression.

RESULTS

Three RCTs (5274 patients) were included. Denosumab was not significantly superior to ZA in reducing the likelihood of spinal cord compression, when all tumor types were combined (odds ratio [OR] 0.92, 95% confidence interval [CI; 0.66, 1.28], P = .66). Denosumab was not significantly favored over ZA in endodermal origin (breast and prostate; OR 0.72, 95% CI [0.43, 1.19], P = .20) and mesodermal origin tumors (solid tumors and multiple myeloma; OR 1.10, 95% CI [0.72, 1.69], P = .66).

CONCLUSION

Denosumab does not significantly reduce the likelihood of spinal cord compressions in comparison to ZA in patients with spine metastases. When spinal cord compressions were grouped by tumor origin (endodermal or mesodermal), there remained no significant difference between denosumab and ZA. Further long-term studies are needed to determine the effectiveness of these treatment regimens.

Treatment Strategy for Impending Instability in Spinal Metastases

Backgroud

Determining surgical management of a spinal metastasis is difficult owing to the involvement of multiple factors. The spinal instability neoplastic score (SINS) system is a reliable tool to evaluate instability in spinal metastases. The intermediate SINS (scores 7–12) indicates impending instability, which makes it difficult to determine the proper treatment strategy. In this study, we aimed to compare the initial status and treatment outcomes of a conservative group versus an operative group among patients with spinal metastases with an intermediate SINS of 7–12. Further, we evaluated the time for conversion to surgery in patients who had initially undergone conservative treatment and identified the factors associated with the conversion.

Methods

Among the patients with a spinal metastasis with an intermediate SINS of 7–12 from May 2013 to December 2017, those who were followed up for more than 12 months were enrolled in this study. Patients with signs of a neurologic deficit or cord compression at the initial diagnosis were excluded. Finally, 79 patients (47 in the initially conservative group and 32 in the initially operative group) were enrolled in this study. The performance status, Tomita score, and Tokuhashi score were assessed for group comparison. Components of SINS, the Bilsky grade, and radiosensitivity of tumor were evaluated to determine factors associated with conversion to surgery.

Results

Average follow-up was 20.9 months (range, 12–46 months). The demographic variables, primary cancer type, and performance status were not significantly different between the 2 groups. However, the Tomita score was lower in the initially operative group (p = 0.006). The 1-year treatment outcome assessed based on the change in performance status and vertebral height collapse showed a tendency to deteriorate less in the initially operative group. The rate of conversion to surgery in the initially conservative group was 33% in the first year, after which there was little change in the incidence of conversion. When vertebral body collapse was less than 50% or the tumor was located in the semi-rigid region (T3–T10), the need for conversion to surgery increased statistically significantly (p = 0.039 and p = 0.042, respectively).

Conclusions

The rate of conversion to surgery in initially conservatively treated patients was about 33% in the first year. When a tumor is located in T3–T10 and less than 50% vertebral body collapse is present, surgery may be the better choice than conservative treatment.

How Do Spinal Surgeons Perceive The Impact of Factors Used in Post-Surgical Complication Risk Scores?

When deciding about surgical treatment options, an important aspect of the decision-making process is the potential risk of complications. A risk assessment performed by a spinal surgeon is based on their knowledge of the best available evidence and on their own clinical experience. The objective of this work is to demonstrate the differences in the way spine surgeons perceive the importance of attributes used to calculate risk of post-operative and quantify the differences by building individual formal models of risk perceptions. We employ a preference-learning method - ROR-UTADIS - to build surgeon-specific additive value functions for risk of complications. Comparing these functions enables the identification and discussion of differences among personal perceptions of risk factors. Our results show there exist differences in surgeons' perceived factors including primary diagnosis, type of surgery, patient's age, body mass index, or presence of comorbidities.

Comparison of pre-implant treatment planning and post-implant dosimetry in I-125 spinal metastases brachytherapy

I-125 seed therapy has been developed and used for the treatment of numerous types of malignancies. It has been suggested that post-implant dosimetry deviates from pre-implant treatment planning; however, to the best of our knowledge, very few studies to date have investigated this discrepancy. In the present study, 11 patients with metastatic spinal tumors, who were treated with I-125 seed brachytherapy, were assessed. Pre- and post-implant dosimetry were compared by assessing: Tumor volume, dose distributions and dose volume histograms. The average doses delivered to 90% of the target volume (D90) in the pre-implant planning images of the spine was 119.07 Gy compared with 94.15 Gy in the post-implant dosimetry (P<0.05). The average V100 in the pre-implant planning images of the spine was 97.85% (range, 96.50–99.80%), compared with 84.46% (range, 66.40–96.70%) in the post-implant dosimetry, of the prescribed doses (P<0.05). Furthermore, both the number of needles and the Dmax of the cord differed between the two groups. Nevertheless, the mean gross tumor volume, the number of seeds, and the V150 and V200 were similar between the two groups. The results of the present study suggest that metastatic spinal tumors of the bone received a lower dose than the pre-implant planned dose coverage in I-125 seed brachytherapy.

Prognostic Differences in Patients with Solitary and Multiple Spinal Metastases

Objectives

To investigate the association between the number of metastases to the spine and survival in patients with metastatic spinal cord compression (MSCC), as well as the prognosis difference between patients with solitary spinal metastasis (SSM) and multiple spinal metastases (MSM).

Methods

Three institutional databases were searched to identify all patients who had undergone spinal surgery for metastatic spinal tumors between March 2002 and June 2010. As well as age and gender, preoperative medical conditions were collected from medical records, including primary tumor, preoperative Frankel score, other bone metastases, preoperative Karnofsky performance status (KPS), number of involved vertebrae, pathological fracture metastasis site, serum albumin, sphincter dysfunction and the time of developing motor deficits before surgery. Survival data were obtained from medical records or via telephone follow‐ups. Univariate and multivariate predictors of overall survival for each group were assessed using the Cox proportional hazards model.

Results

The median postoperative survival time was 6.0 ± 0.6 months (95% confidence interval [CI] 4.8–7.2) in patients with SSM and 7.0 ± 1.0 months (95% CI 5.1–8.9) in patients with MSM (P = 0.238). The difference in survival was not significant between groups. Furthermore, univariate analysis showed that the number of spinal metastases had no significant association with survival (P = 0.075). Primary tumor (P = 0.004) and preoperative KPS (P < 0.001) were independent prognostic factors in the whole cohort; primary tumor (P = 0.020), time of developing motor deficit (P = 0.041) and preoperative KPS (P = 0.038) were independent prognostic factors in patients with SSM; while preoperative KPS (P = 0.001) and serum album level (P < 0.001) were independent prognostic factors in patients with MSM.

Conclusion

The number of spinal metastases has not proven to be useful in predicting the prognosis for patients with MSCC. Consequently, more aggressive operations should be considered for patients with multiple spinal metastases.

Advances in personalized treatment of metastatic spine disease

The spine is one of the most common sites of bony metastases, and its involvement leads to significant patient morbidity. Surgical management in these patients is aimed at improving quality of life and functional status throughout the course of the disease. Resection of metastases often leads to critical size bone defects, presenting a challenge to achieving adequate bone regeneration to fill the void. Current treatment options for repairing these defects are bone grafting and commercial bone cements; however, each has associated limitations. Additionally, tumor recurrence and tumor-induced bone loss make bone regeneration particularly difficult. Systemic therapeutic delivery, such as bisphosphonates, have become standard of care to combat bone loss despite unfavorable systemic side-effects and lack of local efficacy. Developments from tissue engineering have introduced novel materials with osteoinductive and osteoconductive properties which also act as structural support scaffolds for bone regeneration. These new materials can also act as a therapeutic reservoir to sustainably release drugs locally as an alternative to systemic therapy. In this review, we outline recent advancements in tissue engineering and the role of translational research in developing implants that can fully repair bone defects while also delivering local therapeutics to curb tumor recurrence and improve patient quality of life.

Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the effect of obesity (body mass index >30 kg/m²) on perioperative morbidity and mortality after surgical decompression of spinal metastases.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality.

RESULTS

There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007).

CONCLUSIONS

Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.

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.

Prognostic effect of factors involved in revised Tokuhashi score system for patients with spinal metastases: a systematic review and Meta-analysis

Background

Cancer patients’ survival time has obviously improved, with the development of systemic treatment techniques. However, the probability of metastases to the vertebrae has also been increased which makes some adverse effects on patients’ quality of life. The prediction of survival plays a key role in choosing therapeutic modality, and Tokuhashi Score was established as one of the most commonly used predictive systems for spinal metastases. Thus, this study was conducted to identify the prognostic effect of factors involved in revised Tokuhashi Score (RTS).

Methods

Two investigators independently retrieved relevant literature on platforms of PubMed, Embase and Cochrane Library. We identified eligible studies through title/abstract and full-text perusing. Data was extracted including general information of studies, participants’ characteristics, therapeutic modality, overall survival and prognostic effect of factors. Hazard ratio (HR) for each factor was synthesized if available through fixed- or random-effect models as appropriate.

Results

A total of 63 eligible studies with 10,411 participants were identified. Overall, cases with thyroid cancer had the highest survival rate, while the ones with non-small cell lung cancer and hepatocellular carcinoma lived for the shorted survival time. Performance status, bone metastasis, number of involved vertebrae, visceral metastasis, primary tumor and neurological status were regarded as significant predictors in 71.4, 40.0, 18.2, 63.4, 73.1 and 44.7% of the involved studies respectively. Thirty-eight articles were included in meta-analysis, and prognostic effects of five factors (apart from primary tumor) were analyzed. Factors were all proved to be significant except comparisons between KPS (Karnofsky Performance Status) 10–40 VS. 50–70 and single VS. multiple spinal metastases.

Conclusion

All factors of RTS were significant on prognosis predicting and should be considered when choosing therapeutic modality for spinal metastases. What’s more, we believe that more accurate prognosis may be obtained after removal of the cut-offs for KPS 10–40 VS. 50–70 and single VS. multiple involved vertebrae.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5139-2) contains supplementary material, which is available to authorized users.

The Role of Prognostic Scoring Systems in Assessing Surgical Candidacy for Patients With Vertebral Metastasis: A Narrative Review

STUDY DESIGN

Narrative review.

OBJECTIVES

To review the relevant literature regarding scoring systems for vertebral metastases and quantify their role in contemporary orthopedic practice.

METHODS

A literature search of PubMed, Google Scholar, and Embase was performed on February 7, 2017. Eight scoring systems were selected for detailed review-7 of which were scores focused solely on patient prognosis (Tokuhashi, Tomita, Bauer, Oswestry Spinal Risk Index, Van der Linden, Rades, and Katagiri). The eighth system reviewed was the Spinal Instability Neoplastic Score, which examines for impending spinal instability in patients with vertebral metastases and represents a novel approach compared with hitherto scoring systems.

RESULTS

The Bauer and Oswestry Spinal Risk Index have the most accurate prognostic predictive ability, with the newer Oswestry Spinal Risk Index being favored by the contemporary literature as it demands less investigation and is therefore more readily accessible. There was a growing trend in studies designed to customize scoring systems for individual cancer pathological subtypes. The Spinal Instability Neoplastic Score shows good reliability for predicting instability among surgeons and oncologists.

CONCLUSIONS

The increased understanding of cancer pathology and subsequent development of customized treatments has led to prolonged survival. For patients with vertebral metastases, this affects surgical candidacy not only on the basis of prognosis but also provides prolonged opportunity for the development of spinal instability. Scoring systems have a useful guidance role in these deciding for/against surgical intervention, but in order to remain contemporary ongoing review, development, and revalidation is mandatory.

Age Stratification of 30-Day Postoperative Outcomes Following Excisional Laminectomy for Extradural Cervical and Thoracic Tumors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate age as an independent predictive factor for perioperative morbidity and mortality in patients undergoing surgical decompression for metastatic cervical and thoracic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.

METHODS

We identified 1673 adult patients undergoing excisional laminectomy of cervical and thoracic extradural tumors. Patients were stratified into quartiles based on age, with Q1 including patients aged 18 to 49 years, Q2 including patients aged 50 to 60 years, Q3 including patients aged 61 to 69 years, and Q4 including patients ≥70 years. Univariate and multivariate regression analyses were performed to examine the association between age and 30-day perioperative morbidity and mortality.

RESULTS

Age was an independent risk factor for 30-day venous thromboembolism (VTE) and reoperation. Patients in Q3 for age had nearly a 4 times increased risk of VTE than patients in Q1 (odds ratio [OR] 3.97; 95% CI 1.91-8.25; P < .001). However, there was no significant difference in VTE between patients in Q4 and Q1 (P = .069). Patients in Q2 (OR 1.99; 95% CI 1.06-3.74; P = .032) and Q4 (OR 2.18; 95% CI 1.06-4.52; P = .036) for age had a 2 times increased risk of reoperation compared with patients in Q1.

CONCLUSIONS

Age was an independent predictive factor for perioperative VTE and reoperation, but there was no clear age-dependent relationship between increasing age and the risk of these perioperative complications.

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.

Prediction of survival in patients with symptomatic spinal metastases: Comparison between the Tokuhashi score and expert oncologists

BACKGROUND

Existing scoring systems have suboptimal accuracy in prognosticating patients with spinal metastases. Currently, there is no superior method in predicting survival. This study aims to compare the accuracy of survival prediction by expert oncologists versus the revised Tokuhashi scores with actual survivals in a cohort of symptomatic spinal metastases patients.

METHODS

All patients who underwent surgical treatment for metastatic spinal tumours in a tertiary hospital between January 2011 to December 2015 were reviewed. Each patient's data was reconstructed into an anonymised clinical scenario and presented independently to five blinded attending oncologists with at least three years' post fellowship experience. They were surveyed for survival prediction twice at no less than four weeks' interval apart; the test-retest reliability was examined. The agreement of their prognostication and modified Tokuhashi scores were compared with actual survivals.

RESULTS

Fifty-five patients were included during the study period. The mean age at presentation was 61.1 years (range, 41 to 79), and mean actual survival was 21.6 months (range, 1 to 68). Cohen's kappa agreement with actual survival was higher by oncologists' estimation (0.52) than by revised Tokuhashi score prediction (0.31) (p = 0.018). Intra-class correlation showed high inter-reliability (0.71) between the five oncologists and a high test-retest reliability (0.69) between both rounds of the survey.

CONCLUSION

This study showed that expert oncologists provided more accurate survival prediction than revised Tokuhashi scores in patients with spinal metastases. Future studies are required to identify factors in their assessment that led to improved accuracy.