What Happens to People after Malignant Cord Compression? Survival, Function, Quality of Life, Emotional Well-being and Place of Care 1 Month after Diagnosis

Quality of life in patients with malignant spinal cord compression: a systematic review

INTRODUCTION

Malignant spinal cord compression (MSCC) is an oncological emergency that may result in a devastating combination of malignancy and disability. Existing quality of life (QoL) questionnaires commonly used in MSCC literature (EORTC QLQ-C30, BM-22, Brief Pain Inventory, and Spine Oncology Study Group Outcomes) may not capture all the commonly reported symptoms and lack specificity to MSCC. The primary objective of this systematic review is to determine unmet patient needs and underreported QoL issues and compile a comprehensive list of QoL issues. The secondary objective of this review is to compile all existing QoL tools and questionnaires and determine whether any QoL issues are not addressed in the existing tools currently used in the literature.

METHODS

A literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and February 6, 2023, to compile all QoL issues and existing questionnaires used to assess QoL in patients with MSCC. All study designs were included given that they discussed QoL issues specific to patients with MSCC.

RESULTS

The results of this systematic review identified the most frequently discussed QoL issues in the literature studying MSCC. This included direct symptoms of MSCC such as back pain, paralysis, limb weakness/numbness, and urinary/bowel incontinence. Indirect symptoms coming from radiotherapy treatment such as dysphagia, painful swallowing, mouth pain, dry mouth, diarrhea, fatigue, and nausea/vomiting were also noted. Other symptoms resulting from corticosteroid treatment included difficulty sleeping, blurring of vision, weight gain, and mood disturbance. Patients also experienced psychosocial issues such as anxiety, depression, emotional distress, low self-esteem, concerns about dependence on others, concerns about getting home, and fear about their prognosis and future.

CONCLUSION

This review highlights the QoL issues specific to patients with MSCC and QoL tools capturing these issues. Relevance of QoL issues identified in this systematic review must be prospectively validated by patients and healthcare professionals with experience in treating MSCC.

Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication

STUDY DESIGN

A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT).

OBJECTIVES

Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this.

METHODS

Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated <6 months) and Group 2 (prognosis estimated >6 months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis.

RESULTS

829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4 m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%.

CONCLUSIONS

Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy.

Prognostic Factors in Patients with Metastatic Spinal Cord Compression Secondary to Lung Cancer-A Retrospective UK Single-Centre Study

PURPOSE

Metastatic spinal cord compression (MSCC) is a severe complication of cancer that can lead to irreversible neurological impairment, necessitating prompt recognition and intervention. This retrospective, single-centre study aimed to determine the prognostic factors and survival rates among patients presenting with MSCC secondary to lung cancer.

METHODS AND MATERIALS

We identified 74 patients with epidural metastases-related spinal cord compression and a history of lung cancer through the electronic database of Medway Maritime Hospital in the United Kingdom (UK), spanning the period from April 2016 to September 2021. Among them, 39 were below 55 years old, while 35 were aged 55 years or older; 24 patients were diagnosed with small cell lung cancer (SCLC), and 50 patients had non-small cell lung cancer (NSCLC).

RESULTS

The median overall survival (OS) was 5.5 months, with 52 out of 74 patients dying within 6 months of diagnosis with MSCC. For the entire cohort, the statistically significant variables on multi-variate analysis were cancer type (NSCLC had improved OS), the number of involved vertebrae (one to two vertebrae involvement had improved OS), and the time taken to develop motor deficits (≤10 days to develop motor deficits had worsened OS). For the NSCLC cohort, the statistically significant variables on multivariate analysis were molecular alterations (patients with epidermal growth factor receptor (EGFR) mutation), pre-treatment ambulatory status, Eastern Cooperative Oncology Group (ECOG) performance status, and the time taken to develop motor deficits.

CONCLUSIONS

Within the entire cohort, patients diagnosed with NSCLC and spinal metastases affecting one to two vertebrae exhibited enhanced OS. Within the NSCLC subgroup, those with EGFR mutations who were ambulatory and possessed an ECOG performance status of 1-2 demonstrated improved OS. In both the entire cohort and the NSCLC subgroup, the development of motor deficits within a period of ≤10 days was associated with poor OS.

Prognostic Factors for Bone Survival and Functional Outcomes in Patients With Breast Cancer Spine Metastases

According to the Global Cancer Statistics 2020 report, breast cancer is the most commonly diagnosed cancer worldwide. Patients with mammary cancer live longer due to the continuous optimization of chemotherapy, targeted drugs, and hormone therapy, which will inevitably lead to an increase in the prevalence of metastatic bone tumors. Bone metastasis affects approximately 8% of patients with mammary cancer, with the spine being the most common site. Metastatic neoplasms can invade the centrum and its attachments, leading to local pain, spinal instability, vertebral pathological fractures, spinal cord compression, impaired neurological function, and paralysis, ultimately reducing the quality of life. Multidisciplinary and personalized management using analgesic drugs, endocrine therapy, corticosteroid therapy, chemotherapy, bisphosphonates, immunotherapy, targeted drugs, radiotherapy, and surgery has been advocated for the treatment of spinal metastases. Multiple paradigms and systems have been proposed to determine suitable treatments. In the early stages, the occurrence of metastasis indicates a terminal stage of the tumor process in patients with malignant tumors, implying that their lifespan is limited. As a result, the choice of treatment is heavily influenced by longevity. However, with the development of treatment methods, the lifespan of patients with tumors has considerably increased in recent years. This leads to the choice of patient's treatment, which depends not only on the patient's survival, but also on the radiotherapy or postoperative functional outcomes. Nevertheless, they fall short of determining the variables that affect survival and functional outcomes in histology-specific subgroups of breast cancer. To accurately predict the bone survival and functional outcomes of patients with breast cancer spine metastases a review of prognostic factors was performed.

Comparison of Surgical Outcomes Between Separation Surgery and Piecemeal Spondylectomy for Spinal Metastasis: A Retrospective Analysis

Objective: This study aimed to compare the outcomes between piecemeal spondylectomy and separation surgery for patients with spinal metastasis.

Summary of Background Data: Piecemeal spondylectomy and separation surgery are two widely-used treatment options for spinal metastasis. However, no studies have compared the surgical outcomes between both treatment modalities.

Methods: Patients with spinal metastasis who underwent piecemeal spondylectomy or separation surgery between August 2017 and April 2020 at our spine center were recruited. Demographic, preoperative, perioperative, and follow-up data were collected and analyzed. Kaplan–Meier analysis and the log-rank test were used to analyze overall survival (OS) and progression-free survival (PFS) in patients with spinal metastasis.

Results: Overall, 26 patients were treated with piecemeal spondylectomy, and 29 underwent separation surgery with postoperative stereotactic radiosurgery. Both groups showed significant postoperative improvements in neurological status. The piecemeal spondylectomy group had significantly more blood loss (1784.62 ± 833.64 vs. 1165.52 ± 307.38 ml) and required longer operative time (4.76 ± 0.93 vs. 3.73 ± 1.15 h) than the separation surgery group. No significant difference in OS was found between the groups (P = 0.064); however, patients in the separation surgery group experienced less local recurrence than those in the piecemeal spondylectomy group (P = 0.0014). Notably, significant differences were detected in the development of complications between the groups (P = 0.029).

Conclusion: Separation surgery led to less blood loss and reduced complications and had shorter operation time than piecemeal spondylectomy. Although no significant differences were found in OS between the groups, separation surgery was associated with better PFS compared with piecemeal spondylectomy. These findings suggest that separation surgery has some advantages over piecemeal spondylectomy for patients with spinal metastatic disease.

Evaluating ambulatory function as an outcome following treatment for spinal metastases: a systematic review

BACKGROUND CONTEXT

Studies regarding treatment of spinal metastases are critical to evidence-based decision-making. However, variation exists in how a key outcome, ambulatory function, is assessed.

PURPOSE

To characterize the sources and tools investigators have used to evaluate ambulatory function as an outcome following treatment of spinal metastases. We also sought to understand the ways ambulatory function has been conceptualized in prior studies.

STUDY DESIGN

Systematic review of the literature.

PATIENT SAMPLE

We identified 44 published studies for inclusion. Samples within these investigations ranged from 20 to 2,096 subjects.

OUTCOME MEASURES

We describe the methods investigators have used to evaluate ambulatory function following treatment for spinal metastases.

METHODS

We conducted a systematic review through PubMed, Scopus and Web of Science following PRISMA guidelines. We included studies that consisted of adult patients receiving operative or non-operative treatment for spinal metastases. We also required that study investigators specified post-treatment ambulatory function as an outcome. We recorded year of publication, study design, types of spinal metastases included in the study, treatments employed, and sample size. We also described the source (medical record, study-specific observer and/or provider, patient and/or participant), tool (standardized measure, quantitative, qualitative) and concept (eg, ambulatory vs. non-ambulatory; independent ambulation vs. ambulatory with assistance vs. non-ambulatory) used to assess ambulatory function.

RESULTS

We found the plurality of studies relied on medical record documentation as their source. Amongst prospective studies, only a minority used a quantitative measure (eg, prespecified degree of walking ability) to assess ambulatory function. Most studies conceptualized ambulatory function as a dichotomized outcome, typically ambulatory versus non-ambulatory or a similar equivalent.

CONCLUSIONS

Wide variation exists in how ambulatory function is defined in studies involving patients with spinal metastases. We suggest several improvements that will allow a more robust assessment of the quality and quantity of ambulatory function among patients treated for spinal metastases.

Surgical Intervention for Patients With Spinal Metastasis From Lung Cancer: A Retrospective Study of 87 Cases

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

Evaluate the prognosis and surgical outcomes of patients with spinal metastasis from lung cancer undergoing surgical treatment.

SUMMARY OF BACKGROUND DATA

The spine is the most common site of metastatic lesions in patients with lung cancer. There have been a few studies, all small cohorts studying prognosis and surgical outcomes and the results were discordant.

MATERIALS AND METHODS

A retrospective study on a prospectively collected database was conducted. Data collected were the following: age, tobacco use, tumor histology, American Spinal Injury Association score, revised Tokuhashi score, ambulatory status, perioperative complications, postoperative adjuvant treatment, and survival time. Univariate and multivariate analyses were performed to identify the prognostic factors of survival.

RESULTS

The authors studied 87 patients with a mean age of 61.3±1.9 years. Median survival was 4.1±0.8 months. Twenty-eight patients (32.2%) lived >6 months and 14 patients (16.1%) lived >12 months. The medical complication rate was 13.8% and the surgical complication rate was 5.7%. The 30-day mortality rate was 4.6%. Univariate analysis showed tobacco use, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, postoperative walking ability, postoperative radiotherapy, and postoperative chemotherapy were prognostic factors. There was no significant difference in survival between adenoma lung cancers, nonadenoma lung cancers, and small cell lung cancers (P=0.51). Multivariate analysis revealed tobacco use, revised Tokuhashi score, postoperative walking ability, postoperative radiotherapy, and postoperative chemotherapy affected the survival.

CONCLUSIONS

This is the largest reported study of patients with spinal metastasis from lung cancer undergoing spinal surgery. It is the first study showing that tobacco use has a negative impact on survival. Spinal surgery improves the quality of life and offers nonambulatory patients a high chance of regaining walking ability with an acceptable risk of complications.

Predictors of overall survival in non-small-cell lung cancer patients with metastatic spinal cord compression treated with short-course radiotherapy

Metastatic spinal cord compression (MSCC) is a condition that impacts directly on the patient's prognosis.

OBJECTIVE

The study purpose was to identify predictors of overall survival in non-small-cell lung cancer (NSCLC) patients with MSCC.

METHODS

A cohort study involving NSCLC patients enrolled between 2008 and 2017 was performed. Sixty-four patients treated with short-course radiotherapy were included. Clinical and socio-demographic data were extracted from medical records. Data were analysed using survival analysis and Cox proportional hazard regression analysis.

RESULTS

The median survival time was 2.5 months (95% CI: 1.6-3.5). Patients >60 years had shorter survival than younger patients (HR 1.85; 95% CI 1.06-3.24; p = 0.02), and patients with performance status (PS) >2 had shorter survival than those with PS≤2 (HR 1.93; 95% CI 1.12-3.33; p = 0.01).

CONCLUSION

This study found worse PS and higher age are independent predictors of overall survival in NSCLC patients with MSCC treated with short-course radiotherapy after adjusting the potential confounding factors (PS, age and target therapy).

Spine metastasis in patients with prostate cancer: Survival prognosis assessment

BACKGROUND

Patients presenting spine metastasis (SpM) from prostate cancer (PC) form a heterogeneous population, through this study, we aimed to clarify and update their prognostic assessment.

METHODS

The patient data used in this study was obtained from a French national multicenter database of patients treated for PC with SpM between 2014 and 2017. A total of 72 patients and 365 SpM cases were diagnosed.

RESULTS

The median overall survival time for all patients following the event of SpM was 28.8 months. First, we identified three significant survival prognostic factors of PC patients with SpM: good Eastern Cooperative Oncology Group/World Health Organization personnel status (Status 0 hazard ratio [HR]: 0.031, 95% confidence interval [CI]: 0.008-0.127; p < .0001) or (Status 1 HR: 0.163, 95% CI: 0.068-0.393; p < .0001) and SpM radiotherapy (HR: 2.923, 95% CI: 1.059-8.069; p < .0001). Secondly, the presence of osteolytic lesions of the spine (vs. osteoblastic) was found to represent an independent prognosis factor for longer survival [HR: 0.424, 95% CI: 0.216-0.830; p = .01]. Other factors including the number of SpM, surgery, extraspinal metastasis, synchrone metastasis, metastasis-free survival, and SpM recurrence were not identified as being prognostically relevant to the survival of patients with PC.

CONCLUSION

Survival and our ability to estimate it in patients presenting PC with SpM have improved significantly. Therefore, we advocate the relevance of updating SpM prognostic scoring algorithms by incorporating data regarding the timeline of PC as well as the presence of osteolytic SpM to conceive treatments that are adapted to each patient.

Survival in breast cancer patients with spine metastases: Prognostic assessment involving molecular markers

BACKGROUND

To clarify and update the prognostic assessment for heterogeneous population of patients with breast cancer and spine metastases (SpM), using molecular markers.

METHODS

The patient data used in this study was obtained from a French national multi-center database of patients treated for breast cancer with SpM between 2014 and 2017. 556 SpM cases were diagnosed.

RESULTS

Median overall survival (OS) time for all patients following the SpM event was 43.9 months. First, we confirmed 3 previously known significant prognostic factors for survival of patients with SpM: young age [HR: 2.019, 95% CI 1.343-3.037; p = 0.001], good WHO status [ Status 0 HR: 2.823, 95% CI 1.231-3.345; p < 0.0001] or [ Status 1 HR: 1.956, 95% CI 0.768-2.874; p = 0.001] and no-ambulatory neurological status: Frankel A-C [HR: 0.438, 95% CI 0.248-0.772; p = 0.004]. Secondly, we determined the effect of gene mutations on survival in patients with SpM, and we identified that HER2+ cancer subtype [HR: 1.567, 95% CI 0.946-2.557; p = 0.008] was an independent predictor of longer survival, whereas basal cancer subtype [HR: 0.496, 95% CI 0.353-0.699; p < 0.0001] was associated with a poorer prognosis. Other factors including the number of SpM, surgery, extraspinal metastases, synchrone metastases, metastasis-free survival, and SpM recurrence were not identified as prognostically relevant to survival.

CONCLUSION

Survival and our ability to estimate it in breast cancer patients with SpM has improved significantly. Therefore, SpM prognostic scoring algorithms should be updated and incorporate genotypic data on subtypes to make treatment more adaptive.

Vertebrectomy in metastatic spinal tumours: A 10 year, single-centre review of outcomes and survival

Metastatic disease to the vertebral column can cause spinal instability, neurological deterioration and pain. The present study was designed to provide insight into the cohort undergoing vertebrectomy for metastatic disease to the spinal column, assessing the associated morbidity, functional outcomes and survival. A retrospective review of 141 consecutive vertebrectomies for metastatic disease was undertaken. The procedures were performed between 2006 and 2016 at a single institution. Medical records were reviewed and data was obtained regarding primary malignancy, presenting symptoms, pre-operative chemotherapy or radiotherapy, Spinal Instability Neoplastic Score, neurological function, operative approach and duration, blood loss, transfusion requirement, complications, survival, delayed neurological deterioration and construct failure. Long-term follow-up data was available for 123 patients. Forty-two patients were alive at the time of review with a mean survival of 464 days. Post-operative neurological function was preserved or improved in 96.5% of patients. Five patients suffered a neurological deterioration post-operatively. The major complication rate was 19.8% with the most frequent complication being wound infection or dehiscence requiring revision. There were four inpatient deaths. Mean operative time was 240 min. Mean blood loss was 1490 mls. When assessing results by age, no significant difference with respect to complications, neurological outcomes or survival was demonstrated in patients over age 65. There was a significant reduction in survival and higher complication rates in patients who were non-ambulatory following vertebrectomy. Vertebrectomy is a safe and effective means of providing circumferential neural decompression and stabilization with an acceptable complication rate in patients with vertebral metastases, irrespective of age.

Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France

INTRODUCTION

The occurrence of spinal metastasis is a turning point in the progression of cancer. The optimal management has not been well defined. The aim of this study was to identify the various treatments currently being used in France and to determine the benefits of surgical treatment.

MATERIAL AND METHODS

The records of patients treated between 2011 and 2015 at seven spine surgery centers in France were reviewed retrospectively. The pain level (VAS), McAfee scale, walking ability and Frankel Grade were evaluated at inclusion and at 6-months postoperative. The Tomita and Tokuhashi prognostic scores were also determined.

RESULTS

The cohort consisted of 319 patients. Preoperatively, 63.5% of patients could walk without assistance and 66% were Frankel Grade E. Twenty percent of patients were bed-ridden according to the Karnofsky Performance Status. According to the Tokuhashi criteria, 44% were predicted to have less than 6 months to live. The Tomita score recommended palliative surgery in 48% of cases. Potentially unstable lesions were present in 67% of patients. The surgical indication was made because of a neurological deficit in 40% of cases, to alleviate pain in 30% of cases, and for an instability in 30% of cases. Spinal cord decompression and posterior fixation were the most common procedures. The overall complication rate was 38.6%. At 6-months postoperative, 24 patients had died of the 245 available for review. Only 13 patients could not walk (5.3%), 69.4% of patients were Frankel Grade E and pain levels were significantly lower that preoperatively (2.4 vs. 4.6, p<0.001).

DISCUSSION

This study's findings are evidence of the difficulties encountered when treating spinal metastases. The main prognostic scores do not appear to be valid for these patients. A large number of patients were operated urgently because of a neurological deficit, before the treatment could be discussed in a multidisciplinary team (MDT) meeting. Nevertheless, the surgical treatment of these patients is associated with an acceptable complication rate and clinical improvement.

CONCLUSION

Surgical treatment of spinal metastases is not well standardized; thus many different strategies are used. There is evidence that it improves the quality of life in most patients by reducing their pain and allowing them to walk again. However, this treatment must be discussed in the context of an MDT meeting before it is carried out. These patients should be evaluated early on by a spine surgeon to reduce the need for emergency surgery when a neurological deficit appears.

Metastatic epidural spinal cord compression

INTRODUCTION

Metastatic epidural spinal cord compression (MESSC) is a frequent event in patients affected by solid tumor metastases. Current available approaches for MESCC include corticosteroids, radiotherapy and surgery. In the last few years, surgery has evolved from decompression by laminectomy alone, with the introduction of instrumentation systems by metalware (screws and hooks), and this has been associated to an improvement of clinical results compared to radiotherapy alone. Areas covered: In this narrative review, we outline the phases of management of cancer patients affected by MESSC, and discuss the timing of treatments, their impact on the Quality of life (QoL), and the relative benefits and harms of surgery and radiotherapy. Expert commentary: Despite the fact that clinical and surgical trials will be required to determine the most appropriate surgical technique and timing of surgery, we do expect a newer and more important role for radiotherapy in the management of MESCC patients in the next future. In particular, the implementation of radiotactic stereosurgery as adjuvant to decompressive surgery is expected to increase in the next few years, above all in those patients that can be candidate to the so called separation surgery.

Quality of life in patients with malignant spinal cord compression: a review of evidence-based literature

Malignant spinal cord compression (MSCC) is a devastating complication of metastatic cancer. The majority of existing studies focus on treatment guidelines for MSCC, with little emphasis on the impact that MSCC has on quality of life (QoL) for this patient group. This literature review aims to critically appraise available literature focusing on QoL for patients with MSCC. Relevant literature was identified from key electronic databases. A dearth of credible studies representative of the patient population with MSCC was found. Thematic analysis was used as a guide to identify key themes that impact on QoL. Interestingly, patients with MSCC generally report good QoL and low levels of distress in over 50% of cases. However, a significant percentage of patients are distressed. The review concludes that increased awareness and further research into the impact of MSCC is required.

Incidence, associated factors, and survival in metastatic spinal cord compression secondary to lung cancer

BACKGROUND CONTEXT

Bone metastasis (BM) occurs frequently in patients with lung cancer (LC). The most affected are the bones of the spine, increasing the risk of developing metastatic spinal cord compression (MSCC). Although MSCC is one of the most disabling complications, few studies have reported relevant results related to its frequency and prognosis among patients with LC.

PURPOSE

The purpose of this study was to determine the incidence and associated factors of the development of MSCC after BM with LC and its prognosis.

STUDY DESIGN/SETTING

This is a cohort study.

PATIENT SAMPLE

A cohort of 112 patients with BM because of LC, whose treatment was performed exclusively at the National Cancer Institute, was analyzed.

OUTCOME MEASURES

Study outcome measures included incidence of MSCC, factors associated with MSCC, and survival analysis.

METHODS

A cohort study was performed involving patients with BM because of LC diagnosed between 2007 and 2011. Clinical and sociodemographic data were extracted from the physical and electronic medical records because of initial diagnosis (up until December 2013). The association between the independent variables and the outcomes was performed by using crude and adjusted odds ratios (ORs), assuming 95% confidence intervals (CIs). For the exploratory evaluation between the independent variables and the time until the outcomes, Kaplan-Meier survival analysis was conducted. To identify if the differences between the curves were statistically significant, a log-tank test was calculated. A Cox multiple regression model, using the forward stepwise method, was applied, aiming to estimate the factors associated with time to death in the different exposure groups.

RESULTS

Of the 112 patients with BM, 31 (27.7%) developed MSCC. The univariate analysis showed that patients with three or more involved vertebrae revealed a 6.1 times greater risk of developing MSCC, compared with those with up to two metastatic vertebrae involved (OR: 6.1, 95% CI: 2.5-15.1, p<.001). Among the patients who developed MSCC, the median survival time was 4.4 months (95% CI: 1.5-7.3) and 4.7 months (95% CI: 3.5-5.9) in the patients without MSCC, not being a statistically significant difference (p=.19). After the occurrence of the MSCC, the median survival time was 2.8 months (95% CI: 1.4-4.1).

CONCLUSIONS

In this study, a high incidence of MSCC was observed in patients with BM. The study suggests that patients with three or more involved vertebrae per metastasis are more likely to develop MSCC. No alteration in the overall survival time was noticed among the patients with or without MSCC.

Mortality and longevity after a spinal cord injury: systematic review and meta-analysis

BACKGROUND/AIMS

Mortality and longevity studies of spinal cord injury (SCI) are essential for informing healthcare systems and policies. This review evaluates the current evidence among people with SCIs worldwide in relation to the WHO region and country income level; demographic and lesion characteristics; and in comparison with the general population.

METHODS

A systematic review of relevant databases for original studies. Pooled estimates were derived using random effects meta-analysis, restricted to traumatic SCI.

RESULTS

Seventy-four studies were included. In-hospital mortality varied, with pooled estimates of 24.1% (95% confidence interval (CI) 14.1-38.0), 7.6% (95% CI 6.3-9.0), 7.0% (95% CI 1.5-27.4), and 2.1% (95% CI 0.9-5.0) in the WHO regions of Africa, the Americas, Europe and Western Pacific. The combined estimate for low- and middle-income countries was nearly three times higher than for high-income countries. Pooled estimates of first-year survival were 86.5% (95% CI 75.3-93.1), 95.6% (95% CI 81.0-99.1), and 94.0% (95% CI 93.3-94.6) in the Americas, Europe and Western Pacific. Pooled estimates of standardized mortality ratios in tetraplegics were 2.53 (2.00-3.21) and 2.07 (1.47-2.92) in paraplegics.

CONCLUSION

This study found substantial variation in mortality and longevity within the SCI population, compared to the general population, and between WHO regions and country income level. Improved standardization and quality of reporting is needed to improve inferences regarding the extent to which mortality outcomes following an SCI are related to healthcare systems, services and policies.

Reassessment of scoring systems and prognostic factors for metastatic spinal cord compression

BACKGROUND CONTEXT

The incidence of metastatic spinal cord compression (MSCC) is increasing, paralleling increasing life expectancy of patients. However, management of MSCC and relevance of scoring systems remain controversial.

PURPOSE

The aims of our study were to analyze the feasibility and outcomes of spinal surgery, to identify prognostic factors for survival, and to assess the accuracy of scoring systems in patients with malignancies associated with MSCC.

STUDY DESIGN

Retrospective analysis of all patients with MSCC operated in our institution.

METHODS

Outcomes of surgery, prognostic factors for survival, and relevance of Tomita and Tokuhashi scores were investigated.

RESULTS

One hundred forty-eight patients were included: 66% were hyperalgic (pain score >6) and Frankel score (FS) was decreased in 49%. Seventy-three percent of patients had laminectomy with spinal fixation. After surgery, pain decreased in 75% of cases, FS was improved in 31%, and 92% of patients were ambulatory. Postoperative complication rate was 16%. Median overall survival (OS) was 8.9 months (95% confidence interval, 4.4-13). Only Tokuhashi score was relevant, but predictive accuracy of survival was just 51%. In univariate analyses, hyperalgia (p=.001), primary tumor site, extrabone metastases (p<.001), Karnofsky performance status (KPS) less than 70 (p<.001), poor American Society of Anesthesiologist (ASA) score (p<.001) or FS (p=.01), and absence of postoperative chemotherapy (p<.001) were associated with shorter OS. In multivariate analysis, only extrabone metastases (p=.004), KPS (p=.001), and ASA score (p=.007) remained significantly associated with OS.

CONCLUSIONS

Surgery for MSCC is associated with limited morbidity, improved autonomy, and pain relief. Usual scores do not seem relevant, whereas ASA score, KPS, and extrabone metastases are significantly associated with OS.

Long-term survivors after surgical management of metastatic spinal cord compression

PURPOSE

Metastatic spinal cord compression (MSCC) incidences are increasing. Our objective was to identify predictive factors involved in long-term survival after use of a surgical approach.

METHODS

We retrospectively analyzed all patients referred to our institution for MSCC who underwent surgery (N = 138). We identified patients with an overall survival (OS) rate greater than 2 years, compared their characteristics to the remaining patients, and performed recursive partitioning analysis (RPA).

RESULTS

Median OS was 7.8 months (95 % confidence interval 4.4-11.2). Thirty-nine patients presented with OS ≥2 years. A comparative analysis found significant differences concerning the delay (first symptom-surgery, p < 0.001), number of systemic (p = 0.001) or bone metastases (p = 0.013), Karnofsky performance status (KPS) (p = 0.006), Frankel (p = 0.025), ASA scores (p < 0.001), weight loss (p = 0.003), hyperalgia (p = 0.002), chemotherapy use (p = 0.034), and primary tumor (p < 0.001). RPA classification identified six prognostic classes based on the ASA score, primary type, KPS, and systemic metastases.

CONCLUSION

Long-term metastatic cancer survivor patients are an increasing population with specific characteristics.

Healthcare costs associated with skeletal-related events in breast cancer patients with bone metastases

BACKGROUND

Patients with bone metastases secondary to breast cancer are pre-disposed to skeletal-related events (SREs), including spinal cord compression (SCC), pathologic fracture (PF), surgery to bone (SB), and radiotherapy to bone (RT).

OBJECTIVE

To document current patterns of healthcare utilization and costs of SREs in patients with breast cancer and bone metastases.

METHODS

This was a retrospective, observational study using the Thomson MedStat MarketScan Commercial Claims and Encounters database from 9/2002 to 6/2011. Study subjects included all persons with claims for breast cancer and for bone metastases, and ≥1 claims for an SRE. Unique SRE episodes were identified based on a gap of at least 90 days without an SRE claim, and classified by treatment setting (inpatient or outpatient) and SRE type (SCC, PF, SB, or RT).

RESULTS

Of 17,266 patients with breast cancer and bone metastases, 9142 (53%) had one or more SRE episodes. Among 5809 patients who met all other criteria, there were 7617 SRE episodes over mean (SD) follow-up of 17.2 (15.2) months. The percentage of episodes that required inpatient treatment ranged from 11% (RT) to 76% (SB). On average, inpatient SCC episodes (n=83 episodes) were most costly; while outpatient PF episodes (n=552 episodes) were least costly. Of the total SRE costs (mean [SE] $21,072 [$36,462]/episode), 36% were attributable to outpatient RT (n=5265 episodes) and 31% to inpatient PF (n=838 episodes).

LIMITATIONS

The administrative claims data used in this study may lack sensitivity and specificity for identification of clinical events and may not be generalizable to other populations. Also, for some SRE episode categories, the number of events was small and cost estimates may lack precision.

CONCLUSION

In patients with breast cancer and bone metastases, SREs are associated with high costs and hospitalizations.

Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment

BACKGROUND

Radiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment.

METHODS

The study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment.

RESULTS

The most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement.

CONCLUSION

Radiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.

Rehabilitation and treatment of spinal cord tumors

CONTEXT

Due to advances in acute oncological treatment, patients with spinal cord tumors exhibit improved survival. However, these patients have not received the full benefits of rehabilitation services to address their neurological deficits and rehabilitation goals.

OBJECTIVE

To evaluate the epidemiology and pathophysiology of spinal cord tumors, address methods of acute oncological management, review treatment for neurological sequelae, and understand the implications as they relate to rehabilitation.

METHODS

An extensive literature review was performed regarding the epidemiology, pathophysiology, acute oncological management, neurological sequelae, and rehabilitation for patients with spinal cord tumors. Databases used included pubmed.gov and OVID, as well as individual journal and textbook articles.

RESULTS

Access to treatment should be increased given improved survival and functional deficits for patients with spinal cord tumors. Individuals can benefit from inpatient rehabilitation programs, in spite of increased medical co-morbidity and neurological deficits. Specific areas of improvement include functionality, mood, quality of life, and survival. Adjustments to treatment plans must incorporate medical complications from cancer and its treatment, perceived quality of life, and prognosis.

CONCLUSIONS

Patients with spinal cord tumors who participate in rehabilitation programs show general improvement in function, mood, quality of life, and survival. Adaptations to care plans should be made to accommodate medical co-morbidities from cancer and its treatment, patient perceptions, and prognosis.

Radiotherapy or surgery for spine metastases?

BACKGROUND AND PURPOSE

Radiotherapy (RT) remains the cornerstone of management of spine metastases (SM), even though surgery is a well-established treatment for selected patients. We compared the use of RT and surgery in a population-based cohort of patients with SM, investigated pre-treatment factors that were associated with use of these treatment modalities, and examined survival.

PATIENTS AND METHODS

903 patients in the south-eastern Norway who were admitted for RT or surgery for SM for the first time during an 18-month period in 2007-2008 were identified and their medical records were reviewed.

RESULTS

The primary treatment was surgery in 58 patients and RT in 845 patients, including 704 multiple-fraction (MF) and 141 single-fraction (SF) RT schedules. 11 of 607 patients without motor impairment (2%) and 47 of 274 patients with motor impairment (17%) underwent primary operations. 11 of 58 operated patients and 244 of 845 irradiated patients died within 2 months after the start of treatment. 26% of those who received multiple-fraction RT or surgery died within 2 months.

INTERPRETATION

Motor impairment was the main indication for surgery. Better identification of patients with short survival is needed to avoid time-consuming treatment (major surgery and long-term RT).

Survival after rehabilitation for spinal cord injury due to tumor: a 12-year retrospective study

Metastatic spinal cord compression occurs in 2.5% of cancer patients in the last 5 years of life. Spinal cord injury (SCI) due to tumors accounts for 26-45% of non-traumatic SCI. With the aging population and improving survival, the number of patients with SCI due to tumor who have the capacity to benefit from rehabilitation is increasing. This study planned to document survival in patients with primary and secondary tumors causing SCI admitted to a spinal rehabilitation unit over a 12-year period. This is a retrospective open-cohort case series of patients admitted to a Spinal Rehabilitation Unit between 1 July 1996 and 30 June 2008 with a diagnosis of tumor causing SCI. Linkage to the Registry of Births, Deaths and Marriages (Victoria) was used to calculate survival in months following discharge from inpatient rehabilitation. 108 patients were included in the study cohort of which 62% (n = 67) were male. The median age was 61.5 years (IQR 53.6-74). The majority of patients had paraplegia (n = 97, 89.8%) and a metastatic tumor (n = 71, 65.7%) causing their SCI. Most (n = 78, 72%) patients died during the study period. The median survival for primary tumors was significantly greater (Cox regression HR = 1.8, P = 0.03) 9.5 months (IQR 2.8-34.4 months) than that for metastatic tumors (median 2.8, IQR 1.2-9.0 months).

CONCLUSION

Patients with longer survival are appropriate for rehabilitation programs targeting longer-term goals whilst patients with shorter survival are more suitable for short, directed rehabilitation programs.

Effects of gender on inpatient rehabilitation outcomes in the elderly with incomplete paraplegia from nontraumatic spinal cord injury

OBJECTIVE

To examine gender differences in rehabilitation outcomes for patients with nontraumatic spinal cord injury.

RESEARCH DESIGN

Secondary analysis was conducted on Medicare beneficiary data from 65 to 74 year olds with incomplete paraplegia discharged from inpatient rehabilitation facilities in 2002 through 2005.

MAIN OUTCOME MEASURES

Length of stay, Functional Independence Measure instrument motor item and subscale scores on discharge, and discharge destination.

RESULTS

Among patients with degenerative spinal disease, men had significantly longer rehabilitation stays than women (P < 0.001). Men with degenerative spinal disease had significantly lower discharge Functional Independence Measure scores than women, indicating more dependence in self-care (P < 0.001) and mobility (P < 0.001). Among patients with degenerative spinal disease, men were less likely to walk (odds ratio = 0.58; 95% CI = 0.38-0.87) and less likely to be independent with bladder management (odds ratio = 0.44; 95% CI = 0.31-0.62). Among patients with vascular ischemia, men were more independent (B = 2.59; 99% CI = 0.42-4.76) in mobility than women. There were no gender differences in the malignant spinal tumors group. There were no gender differences in being discharged to a community-based residence.

CONCLUSIONS

Gender distributions varied by etiology. Gender differences were found in demographics, length of stay, and functional outcomes but not discharge destination. Men were more dependent than women at discharge in the etiology group with the least overall disability (degenerative spinal disease) and more independent in mobility than women at discharge in the etiology group with the most overall disability (vascular ischemia).

Morbidity and mortality in patients with cancer who become nonambulatory after spinal cord compression: a case series on end-of-life care

BACKGROUND

Few studies have focused on the outcomes of nonambulatory patients diagnosed with spinal cord compression from metastatic cancer. The purpose of this study was to review the morbidity and mortality suffered by these patients.

METHODS

Over a 10-year period (1996-2006), a retrospective review was undertaken to assess the outcomes of 39 nonambulatory patients diagnosed with spinal cord compression from metastatic cancer.

RESULTS

Treatment for cord compression included corticosteroids (n = 33), radiation (n = 25), and surgical decompression (n = 13). Nonetheless, 23 patients (59%) required bowel and/or bladder catheterization, and 33 (85%) required pain medications. Twenty-five (64%) did not regain ambulation. Only 13 patients (33%) went home without assistance. In contrast, 10 (26%) were transferred to a nursing home, 6 (15%) were sent home with hospice, 5 (13%) went home with home health care, and 1 (3%) was moved to a hospice inpatient facility. At the time of this report, all patients had died with a median survival of 76 days (range, 4-1975 days). Long-term survivors who lived beyond a year were primarily patients who had regained ambulation.

CONCLUSION

Metastatic cord compression causes severe morbidity and compromised survival in patients who become nonambulatory. Future palliative care efforts should focus on further characterizing and addressing these needs.

Effects of etiology on inpatient rehabilitation outcomes in 65- to 74-year-old patients with incomplete paraplegia from a nontraumatic spinal cord injury

OBJECTIVE

To examine differences in rehabilitation outcomes for older patients with a nontraumatic spinal cord injury (NT-SCI) for 5 etiologic diagnoses: degenerative spinal disease (DSD), malignant spinal tumor, benign spinal tumor, vascular ischemia, and spinal abscess.

DESIGN

Retrospective cohort study that used Medicare claims and assessment data.

SETTING

A total of 479 inpatient rehabilitation hospitals and units.

PATIENTS

A total of 1780 Medicare beneficiaries (65-74 years old) with incomplete paraplegia attributable to NT-SCI who were discharged from inpatient rehabilitation facilities from 2002 through 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Length of stay, discharge Functional Independence Measure (FIM) instrument motor item and subscale scores, and discharge destination.

RESULTS

Demographic characteristics varied by etiology group. Mean +/- SD rehabilitation stays ranged from 13.3 +/- 7.7 days for DSD to 26.4 +/- 13.4 days for vascular ischemia. Adjusted data showed stays differed (P < .001) across etiology groups. Adjusted discharge mean self-care and mobility subscores revealed that patients with DSD and benign tumor were more independent (P < .001) than patients with a malignant tumor or spinal abscess. Patients with vascular ischemia were more dependent (P < .01) in mobility than the DSD and benign tumor groups. Etiologic differences (P < .01) in independence in discharge FIM modifiers for walking (FIM > or = 4), bladder (FIM > or = 6) and bowel management (FIM > or = 6) and bowel accidents/continence (FIM > or = 6), but not bladder accidents (FIM > or = 6), were present. The percent of patients discharged to a community residence ranged from 59.3% to 92.6%. Adjusted data showed that significantly larger percentages (P < .01) of patients in the DSD and malignant tumor groups than in the spinal abscess group were discharged to a community residence (versus nursing home).

CONCLUSION

There are etiologic differences in demographics, rehabilitation length of stay, functional outcomes, and discharge destination in elderly patients with NT-SCI.

Incidence and treatment patterns in hospitalizations for malignant spinal cord compression in the United States, 1998-2006

PURPOSE

To characterize patterns in incidence, management, and costs of malignant spinal cord compression (MSCC) hospitalizations in the United States, using population-based data.

METHODS AND MATERIALS

Using the Nationwide Inpatient Sample, an all-payer healthcare database representative of all U.S. hospitalizations, MSCC-related hospitalizations were identified for the period 1998-2006. Cases were combined with age-adjusted Surveillance, Epidemiology and End Results cancer death data to estimate annual incidence. Linear regression characterized trends in patient, treatment, and hospital characteristics, costs, and outcomes. Logistic regression was used to examine inpatient treatment (radiotherapy [RT], surgery, or neither) by hospital characteristics and year, adjusting for confounding.

RESULTS

We identified 15,367 MSCC-related cases, representing 75,876 hospitalizations. Lung cancer (24.9%), prostate cancer (16.2%), and multiple myeloma (11.1%) were the most prevalent underlying cancer diagnoses. The annual incidence of MSCC hospitalization among patients dying of cancer was 3.4%; multiple myeloma (15.0%), Hodgkin and non-Hodgkin lymphomas (13.9%), and prostate cancer (5.5%) exhibited the highest cancer-specific incidence. Over the study period, inpatient RT for MSCC decreased (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.61-0.81), whereas surgery increased (OR 1.48, 95% CI 1.17-1.84). Hospitalization costs for MSCC increased (5.3% per year, p < 0.001). Odds of inpatient RT were greater at teaching hospitals (OR 1.41, 95% CI 1.19-1.67), whereas odds of surgery were greater at urban institutions (OR 1.82, 95% CI 1.29-2.58).

CONCLUSIONS

In the United States, patients dying of cancer have an estimated 3.4% annual incidence of MSCC requiring hospitalization. Inpatient management of MSCC varied over time and by hospital characteristics, with hospitalization costs increasing. Future studies are required to determine the impact of treatment patterns on MSCC outcomes and strategies for reducing MSCC-related costs.

Pain after palliative radiotherapy for spine metastases

AIMS

The purpose of the study was to evaluate the response to palliative radiotherapy in patients with painful spinal metastatic disease (SMD).

MATERIALS AND METHODS

Three hundred and fifty-five patients admitted to the Norwegian Radium Hospital for radiotherapy for painful SMD were included in a prospective study and were followed up 2 months later. The Brief Pain Inventory was used to assess pain. Analgesic consumption was recalculated into the daily oral morphine-equivalent dose. The radiotherapy-related response rates were calculated using the criteria of the International Bone Metastases Consensus Group (IBMCG), taking into account the use of concomitant analgesics. The response to radiotherapy was assessed as complete or partial and non-response as stable pain, pain progression or 'other'.

RESULTS

Brief Pain Inventory forms were obtained at follow-up from 229 of the 355 patients. Two months after radiotherapy, the median self-reported worst pain decreased significantly, but the median oral morphine-equivalent dose increased from 40 to 60 mg (P<0.001). Forty-three per cent of the patients reported pain relief, but a radiotherapy-related response was found in 37% of the patients. Overall correspondence between the patients' self-reported changes in pain experience and the IBMCG-based response categories was obtained in 63% of the patients.

CONCLUSIONS

The radiotherapy-related response rates in our study were lower than those reported previously in patients with bone metastases in general, which possibly indicates the presence of more complex pathophysiological mechanisms of pain in SMD.

Depression assessment and classification in palliative cancer patients: a systematic literature review

The objective of this study was to review the literature on depression in palliative cancer care in order to identify which assessment methods and classification systems have been used in studies of depression. Extensive electronic database searches in PubMed, CancerLit, CINAHL, PsychINFO, EMBASE and AgeLine as well as hand search were carried out. In the 202 included papers, 106 different assessment methods were used. Sixty-five of these were only used once. All together, the Hospital Anxiety and Depression Scale (HADS) was the most commonly used assessment method. However, there were regional differences and while the HADS dominated in Europe it was quite seldom used in Canada or in the USA. Few prevalence and intervention studies used assessment methods with an explicit reference to a diagnostic system. There were in total few case definitions of depression. Among these, the classifications were in general based on cut-off scores (77%) and not according to diagnostic systems. The full range of the DSM-IV diagnostic criteria was seldom assessed, i.e. less than one-third of the assessments in the review took into account the duration of symptoms and 18% assessed consequences and impact upon patient functioning. A diversity of assessment methods had been used. Few studies classified depression by referring to a diagnostic system or by using cut-off scores. Evidently, there is a need for a consensus on how to assess and conceptualize depression and related conditions in palliative care.

Suspected malignant cord compression - improving time to diagnosis via a 'hotline': a prospective audit

The aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain +/- severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3-66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans.

Diagnosis and management of malignant spinal cord compression: part 2

Malignant spinal cord compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multidisciplinary care and rehabilitation are paramount in optimising quality of life for the affected individual. The effects of MSCC can range from minor sensory, motor and autonomic changes to severe pain, and complete paralysis that significantly affects the remainder of a patient's quality of life. When caught early, the symptoms of MSCC can be prevented, minimised or possibly reversed. However, failure to recognise the condition and its serious nature, together with limited awareness of the importance of early referral for treatment, can result in irreversible paralysis. Therefore, it is essential that nurses providing clinical care for these at-risk patients are able to identify early symptoms, and undertake a thorough patient history and examination; educating the patient and their family about the signs and symptoms of MSCC that need to be reported as soon as they occur.