Evolution in treatment strategy for metastatic spine disease: Presently evolving modalities

Effect of radiotherapy on local control and overall survival in spinal metastasis of non-small-cell lung cancer after surgery and systemic therapy

Aims

Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS.

Methods

A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis.

Results

Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC.

Conclusion

Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients.

A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis

PURPOSE

As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster.

METHODS

We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale.

RESULTS

Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement.

CONCLUSION

Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.

[Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis (Part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature

Multiple myeloma is a hematological neoplasm that frequently affects the spinal column. Less than a fifth of this vertebral involvement corresponds to the cervical spine and cranio-cervical junction. When there is instability or neurological involvement due to compression or deformity, approaches for anterior decompression and occipitocervical stabilization are required. The correct managment of vertebral artery aneurysm associated with occipitocervical arthrodesis requires extensive knowledge of anatomy and pathology. We present a case of a vertebral pseudoaneurysm that occurred late after the resection of a C1-C2 vertebral body multiple myeloma lesion managed with endonasal endoscopic approach and posterior occipitocervical arthrodesis as well as a systematic review of the related literature. The patient recovered well, without major neurological deficits.

The role of minimally invasive spine surgery in the treatment of vertebral metastasis (part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

Outcomes and Complications of Surgery for Symptomatic Spinal Metastases; a Comparison Between Patients Aged ≥ 70 and <70

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Physicians may be deterred from operating on elderly patients due to fears of poorer outcomes and complications. We aimed to compare the outcomes of surgical treatment of spinal metastases patients aged ≥70-yrs and <70-yrs.

MATERIALS AND METHODS

This is a retrospective study of patients surgically treated for metastatic epidural spinal cord compression and spinal instability between January-2005 to December-2021. Follow-up was till death or minimum 1-year post-surgery. Outcomes included post-operative neurological status, ambulatory status, medical and surgical complications. Two Sample t-test/Mann Whitney U test were used for numerical variables and Pearson Chi-Squared or Fishers Exact test for categorical variables. Survival was presented with a Kaplan-Meier curve. P < .05 was significant.

RESULTS

We identified 412 patients of which 29 (7.1%) patients were excluded due to loss to follow-up and previous surgical treatment. 79 (20.6%) were ≥70-yrs. Age ≥70-yrs patients had poorer ECOG scores (P = .0017) and Charlson Comorbidity Index (P < .001). No significant difference in modified Tokuhashi score (P = .393) was observed with significantly more ≥ prostate (P < .001) and liver (P = .029) cancer in ≥70-yrs. Improved or maintained normal neurological function (P = .934), independent ambulatory status (P = .171), and survival at 6 months (P = .119) and 12 months (P = .659) was not significantly different between both groups. Medical (P = .528) or surgical (P = .466) complication rates and readmission rates (P = .800) were similar.

CONCLUSION

≥70-yrs patients have comparable outcomes to <70-yr old patients with no significant increase in complication rates. Age should not be a determining factor in deciding surgical management of spinal metastases.

The Utility of 'Minimal Access and Separation Surgery' in the Management of Metastatic Spine Disease

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To compare outcomes of percutaneous pedicle screw fixation (PPSF) to open posterior stabilization (OPS) in spinal instability patients and minimal access separation surgery (MASS) to open posterior stabilization and decompression (OPSD) in metastatic spinal cord compression (MSCC) patients.

METHODS

We analysed patients who underwent surgery for thoracolumbar metastatic spine disease (MSD) from Jan 2011 to Oct 2017. Patients were divided into minimally invasive spine surgery (MISS) and open spine surgery (OSS) groups. Spinal instability patients were treated with PPSF/OPS with pedicle screws. MSCC patients were treated with MASS/OPSD. Outcomes measured included intraoperative blood loss, operative time, duration of hospital stay and ASIA-score improvement. Time to initiate radiotherapy and perioperative surgical/non-surgical complications was recorded. Propensity scoring adjustment analysis was utilised to address heterogenicity of histological tumour subtypes.

RESULTS

Of 200 eligible patients, 61 underwent MISS and 139 underwent OSS for MSD. There was no significant difference in baseline characteristics between MISS and OSS groups. In the MISS group, 28 (45.9%) patients were treated for spinal instability and 33 (54.1%) patients were treated for MSCC. In the OSS group, 15 (10.8%) patients were treated for spinal instability alone and 124 (89.2%) were treated for MSCC. Patients who underwent PPSF had significantly lower blood loss (95 mL vs 564 mL; P < .001) and surgical complication rates(P < .05) with shorter length of stay approaching significance (6 vs 19 days; P = .100) when compared to the OPS group. Patients who underwent MASS had significantly lower blood loss (602 mL vs 1008 mL) and shorter length of stay (10 vs 18 days; P = .098) vs the OPSD group.

CONCLUSION

This study demonstrates the benefits of PPSF and MASS over OPS and OPSD for the treatment of MSD with spinal instability and MSCC, respectively.

Ten-year retrospect of the investigation of proximal limbs metastasis in cancer: a multi-center study on survival outcome, limb function status and surgical procedures analysis

BACKGROUND

The aim of study was to evaluate survival outcome and limb function in cancer patients with proximal limbs metastasis. Associated factors on survival outcome and limb function were identified. The comparative analysis between intramedullary nailing and prosthesis surgery in cancer patients with proximal limb metastasis was performed.

METHODS

In this five-center retrospective study, patients diagnosed with limbs metastasis were collected. Descriptive statistics was used and log-rank test was performed to analyze the survival in subgroups. The Cox proportional hazards regression analysis was performed to identify the independent prognostic factors. The Musculoskeletal Tumor Society (MSTS) scoring system was used to evaluate limb function after surgery, and t test or analysis of variance (ANOVA) was utilized in subgroup analysis.

RESULTS

A total of 316 patients with limb metastasis were included with mean age at 61.0 years. The most common primary tumor was breast, followed by renal cancer and lung cancer. The median overall survival was 24.0 months and the 1-, 3- and 5-year survival rates were 86.9%, 34.7% and 6.8%, respectively. Primary tumor type, visceral metastasis and chemotherapy were proved to be the independent prognostic factors. The mean Musculoskeletal Tumor Society (MSTS) score was 20.5, significant difference was observed in subgroup of solitary/multiple bone metastasis, with/without pathological fracture, and type of surgery.

CONCLUSION

The present study concluded that primary tumor type, visceral metastasis and chemotherapy were three factors affecting the survival of patients. Compared with intramedullary nailing, the patients underwent prosthesis surgery showed better limb function, this procedure should be encouraged in patients with indication.

Treatment progress of spinal metastatic cancer: a powerful tool for improving the quality of life of the patients

Spinal metastasis is a common secondary malignant tumor of the bone, often resulting in spinal cord and nerve root compression, leading to obvious pain and related compression symptoms. This condition has a high incidence and mortality rate. The treatment approach for most patients with spinal metastasis is primarily palliative. Consultation with a multidisciplinary team is widely accepted as a comprehensive treatment approach for patients with spinal metastases. With advancements in research and technology, the evaluation and treatment of spinal metastatic cancer are continuously evolving. This study provides an overview of surgical treatment, minimally invasive treatment, and radiotherapy for spinal metastatic cancer and also analyzes the clinical effects, advantages, and current limitations associated with various treatment approaches.

Assessing the Performance of Prognostic Scores in Patients with Spinal Metastases from Lung Cancer Undergoing Non-surgical Treatment

STUDY DESIGN

Retrospective study.

PURPOSE

The purpose of this study was to see how well the Tomita score, revised Tokuhashi score, modified Bauer score, Van der Linden score, classic Skeletal Oncology Research Group (SORG) algorithm, SORG nomogram, and New England Spinal Metastasis Score (NESMS) predicted 3-month, 6-month, and 1-year survival of non-surgical lung cancer spinal metastases.

OVERVIEW OF LITERATURE

There has been no study assessing the performance of prognostic scores for non-surgical lung cancer spinal metastases.

METHODS

Data analysis was carried out to identify the variables that had a significant impact on survival. For all patients with spinal metastasis from lung cancer who received non-surgical treatment, the Tomita score, revised Tokuhashi score, modified Bauer score, Van der Linden score, classic SORG algorithm, SORG nomogram, and NESMS were calculated. The performance of the scoring systems was assessed by using receiver operating characteristic (ROC) curves at 3 months, 6 months, and 12 months. The predictive accuracy of the scoring systems was quantified using the area under the ROC curve (AUC).

RESULTS

A total of 127 patients are included in the present study. The median survival of the population study was 5.3 months (95% confidence interval [CI], 3.7-9.6 months). Low hemoglobin was associated with shorter survival (hazard ratio [HR], 1.49; 95% CI, 1.00-2.23; p =0.049), while targeted therapy after spinal metastasis was associated with longer survival (HR, 0.34; 95% CI, 0.21-0.51; p <0.001). In the multivariate analysis, targeted therapy was independently associated with longer survival (HR, 0.3; 95% CI, 0.17-0.5; p <0.001). The AUC of the time-dependent ROC curves for the above prognostic scores revealed all of them performed poorly (AUC <0.7).

CONCLUSIONS

The seven scoring systems investigated are ineffective at predicting survival in patients with spinal metastasis from lung cancer who are treated non-surgically.

Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study

PURPOSE

Allogeneic blood transfusion (ABT) is current standard of blood replenishment despite known complications. Salvaged blood transfusion (SBT) addresses majority of such complications. Surgeons remain reluctant to employ SBT in metastatic spine tumour surgery (MSTS), despite ample laboratory evidence. This prompted us to conduct a prospective clinical study to ascertain safety of intraoperative cell salvage (IOCS), in MSTS.

METHODS

Our prospective study included 73 patients who underwent MSTS from 2014 to 2017. Demographics, tumour histology and burden, clinical findings, modified Tokuhashi score, operative and blood transfusion (BT) details were recorded. Patients were divided based on BT type: no blood transfusion (NBT) and SBT/ABT. Primary outcomes assessed were overall survival (OS), and tumour progression was evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12 and 24 months, classifying patients with non-progressive and progressive disease.

RESULTS

Seventy-three patients [39:34(M/F)] had mean age of 61 years. Overall median follow-up and survival were 26 and 12 months, respectively. All three groups were comparable for demographics and tumour characteristics. Overall median blood loss was 500 mL, and BT was 1000 mL. Twenty-six (35.6%) patients received SBT, 27 (37.0%) ABT and 20 (27.4%) NBT. Females had lower OS and higher risk of tumour progression. SBT had better OS and reduced risk of tumour progression than ABT group. Total blood loss was not associated with tumour progression. Infective complications other than SSI were significantly (p = 0.027) higher in ABT than NBT/SBT groups.

CONCLUSIONS

Patients of SBT had OS and tumour progression better than ABT/NBT groups. This is the first prospective study to report of SBT in comparison with control groups in MSTS.

Design and 3D printing of novel titanium spine rods with lower flexural modulus and stiffness profile with optimised imaging compatibility

PURPOSE

To manufacture and test 3D printed novel design titanium spine rods with lower flexural modulus and stiffness compared to standard solid titanium rods for use in metastatic spine tumour surgery (MSTS) and osteoporosis.

METHODS

Novel design titanium spine rods were designed and 3D printed. Three-point bending test was performed to assess mechanical performance of rods, while a French bender was used to assess intraoperative rod contourability. Furthermore, 3D printed spine rods were tested for CT & MR imaging compatibility using phantom setup.

RESULTS

Different spine rod designs generated includes shell, voronoi, gyroid, diamond, weaire-phelan, kelvin, and star. Tests showed 3D printed rods had lower flexural modulus with reduction ranging from 2 to 25% versus standard rod. Shell rods exhibited highest reduction in flexural modulus of 25% (~ 77.4 GPa) and star rod exhibited lowest reduction in flexural modulus of 2% (100.8GPa). 3D printed rod showed reduction in stiffness ranging from 40 to 59%. Shell rod displayed highest reduction in stiffness of 59% (179.9 N/mm) and gyroid had least reduction in stiffness of 40% (~ 259.2 N/mm). Rod bending test showed that except gyroid, other rod designs demonstrated lesser bending difficulty versus standard rod. All 3D printed rods demonstrated improved CT/MR imaging compatibility with reduced artefacts versus standard rod.

CONCLUSION

By utilising novel design approach, we successfully generated a spine rod design portfolio with lower flexural modulus/stiffness profile and better CT/MR imaging compatibility for potential use in MSTS/other conditions such as osteoporosis. Thus, exploration of new rod designs in surgical application could enhance treatment outcome and improve quality of life for patients.

Fully Endoscopic Spine Separation Surgery in Metastatic Disease-Case Series, Technical Notes, and Preliminary Findings

Objective: This report aims to describe the surgical methodology and potential effectiveness of endoscopic separation surgery (ESS) in patients with metastatic spine disease. This concept may reduce the invasiveness of the procedure, which can potentially speed up the wound healing process and, thus, the possibility of faster application of radiotherapy. Materials and Methods: In this study, separation surgery for preparing patients for stereotactic body radiotherapy (SBRT) was performed with fully endoscopic spine surgery (FESS) followed by percutaneous screw fixation (PSF). Results: Three patients with metastatic spine disease in the thoracic spine were treated with fully endoscopic spine separation surgery. The first case resulted in the progression of paresis symptoms that resulted in disqualification from further oncological treatment. The remaining two patients achieved satisfactory clinical and radiological effects and were referred for additional radiotherapy. Conclusions: With advancements in medical technology, such as endoscopic visualization, and new tools for coagulation, we can treat more and more spine diseases. Until now, spine metastasis was not an indication for the use of endoscopy. This method is very technically challenging and risky, especially at such an early stage of application, due to variations in the patient's condition, morphological diversity, and the nature of metastatic lesions in the spine. Further trials are needed to determine whether this new approach to treating patients with spine metastases is a promising breakthrough or a dead end.

Evaluation of different scoring systems for spinal metastases based on a Chinese cohort

INTRODUCTIONS

The spine is one of the most common sites of metastasis for malignancies. This study aimed to compare the predictive performance of seven commonly used prognostic scoring systems for surgically treated spine metastases. It is expected to assist surgeons in selecting appropriate scoring systems to support clinical decision-making and better inform patients.

METHODS

We performed a retrospective study involving 268 surgically treated patients with spine metastases between 2017 and 2020 at a single regional oncology center in China. The revised Tokuhashi, Tomita, modified Bauer, revised Katagiri, van der Linden, Skeletal Oncology Research Group (SORG) nomogram, and SORG machine-learning (ML) scoring systems were externally validated. The area under the curve (AUC) of the receiver operating characteristic curve was used to evaluate sensitivity and specificity at different postoperative time points. The actual survival time was compared with the reference survival time provided in the original publication.

RESULTS

In the present study, the median survival was 16.6 months. The SORG ML scoring system demonstrated the highest accuracy in predicting 90-day (AUC: 0.743) and 1-year survival (AUC: 0.787). The revised Katagiri demonstrated the highest accuracy (AUC: 0.761) in predicting 180-day survival. The revised Katagiri demonstrated the highest accuracy (AUC: 0.779) in predicting 2-year survival. Based on this series, the actual life expectancy was underestimated compared with the original reference survival time.

CONCLUSIONS

None of the scoring systems can perform optimally at all time points and for all pathology types, and the reference survival times provided in the original study need to be updated. A cautious awareness of the underestimation by these models is of paramount importance in relation to current patients.

Quantifying the changes in the tumour vascular micro-environment in spinal metastases treated with stereotactic body radiotherapy - a single arm prospective study

BACKGROUND

The primary objective was to quantify changes in vascular micro-environment in spinal metastases (SM) patients treated with stereotactic body radiotherapy (SBRT) with multi-parametric dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI). The secondary objective was to study plasma biomarkers related to endothelial apoptosis.

PATIENTS AND METHODS

Patients were imaged with DCE-MRI at baseline/1-week/12-weeks post-SBRT. Metrics including normalised time-dependent leakage (Ktrans), permeability surface product (PS), fractional plasma volume (Vp), extracellular volume (Ve) and perfusion (F) were estimated using distributed parameter model. Serum acid sphingomyelinase (ASM) and sphingosine-1-phosphate (S1P) were quantified using ELISA. Clinical outcomes including physician-scored and patient-reported toxicity were collected.

RESULTS

Twelve patients (with varying primary histology) were recruited, of whom 10 underwent SBRT. Nine patients (with 10 lesions) completed all 3 imaging assessment timepoints. One patient died due to pneumonia (unrelated) before follow-up scans were performed. Median SBRT dose was 27 Gy (range: 24-27) over 3 fractions (range: 2-3). Median follow-up for alive patients was 42-months (range: 22.3-54.3), with local control rate of 90% and one grade 2 or higher toxicity (vertebral compression fracture). In general, we found an overall trend of reduction at 12-weeks in all parameters (Ktrans/PS/Vp/Ve/F). Ktrans and PS showed a reduction as early as 1-week. Ve/Vp/F exhibited a slight rise 1-week post-SBRT before reducing below the baseline value. There were no significant changes, post-SBRT, in plasma biomarkers (ASM/S1P).

CONCLUSIONS

Tumour vascular micro-environment (measured by various metrics) showed a general trend towards downregulation post-SBRT. It is likely that vascular-mediated cell killing contributes to excellent local control rates seen with SBRT. Future studies should evaluate the effect of SBRT on primary-specific spinal metastases (e.g., renal cell carcinoma).

The predictive ability of routinely collected laboratory markers for surgically treated spinal metastases: a retrospective single institution study

PURPOSE

We aimed to identify effective routinely collected laboratory biomarkers for predicting postoperative outcomes in surgically treated spinal metastases and attempted to establish an effective prediction model.

METHODS

This study included 268 patients with spinal metastases surgically treated at a single institution. We evaluated patient laboratory biomarkers to determine trends to predict survival. The markers included white blood cell (WBC) count, platelet count, neutrophil count, lymphocyte count, hemoglobin, albumin, alkaline phosphatase, creatinine, total bilirubin, calcium, international normalized ratio (INR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR). A nomogram based on laboratory markers was established to predict postoperative 90-day and 1-year survival. The discrimination and calibration were validated using concordance index (C-index), area under curves (AUC) from receiver operating characteristic curves, and calibration curves. Another 47 patients were used as a validation group to test the accuracy of the nomogram. The prediction accuracy of the nomogram was compared to Tomita, revised Tokuhashi, modified Bauer, and Skeletal Oncology Research Group machine-learning (SORG ML).

RESULTS

WBC, lymphocyte count, albumin, and creatinine were shown to be the independent prognostic factors. The four predictive laboratory markers and primary tumor, were incorporated into the nomogram to predict the 90-day and 1-year survival probability. The nomogram performed good with a C-index of 0.706 (0.702-0.710). For predicting 90-day survival, the AUC in the training group and the validation group was 0.740 (0.660-0.819) and 0.795 (0.568-1.000), respectively. For predicting 1-year survival, the AUC in the training group and the validation group was 0.765 (0.709-0.822) and 0.712 (0.547-0.877), respectively. Our nomogram seems to have better predictive accuracy than Tomita, revised Tokuhashi, and modified Bauer, alongside comparable prediction ability to SORG ML.

CONCLUSIONS

Our study confirmed that routinely collected laboratory markers are closely associated with the prognosis of spinal metastases. A nomogram based on primary tumor, WBC, lymphocyte count, albumin, and creatinine, could accurately predict postoperative survival for patients with spinal metastases.

Treatment of Metastatic Spinal Disease; what the Radiologist needs to know

Advancements in technology and multidisciplinary management have revolutionized the treatment of spinal metastases. Imaging plays a pivotal role in determining the treatment course for spinal metastases. This article aims to review the relevant imaging findings in spinal metastases from the perspective of the treating clinician, describe the various treatment options, and discuss factors influencing choice for each available treatment option. Cases that once required radical surgical resection or low-dose conventional external beam radiation therapy, or both, are now being managed with separation surgery, spine stereotactic radiosurgery/stereotactic body radiation therapy, or both, with decreased morbidity, improved local control, and more durable pain control. The primary focus in determining treatment choice is now on tumor control outcomes, treatment-related morbidity, and quality of life.

Risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative radiation therapy

BACKGROUND

Advancements in the field of oncological therapies during the last decades have led to a significantly prolonged survival of cancer patients. This has led to an increase in the incidence of spinal metastases. The purpose of this study was to assess risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative RT and its timing.

METHODS

Patients who had been treated for metastatic spine disease by surgical stabilization followed by radiotherapy between 01/2012 and 03/2019 were included and a retrospective chart review was performed.

RESULTS

Of 604 patients who underwent stabilizing surgery for spinal metastases, 237 patients (mean age 66 years, SD 11) with a mean follow-up of 11 months (SD 7) were eligible for further analysis. Forty-one patients (17.3%) had wound-related complications, 32 of them before and 9 after beginning of the RT. Revision surgery was necessary in 26 patients (11.0%). Body weight (p = 0.021), obesity (p = 0.018), ASA > 2 (p = 0.001), and start of radiation therapy within 21 days after surgery (p = 0.047) were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of surgery (12%) were more likely to have a wound-related surgical revision (p = 0.031).

CONCLUSION

Body weight, obesity and ASA > 2 were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of the surgery were more likely to have a wound-related revision surgery. Patients who had begun radiation therapy within 21 days after surgery were more likely to have a wound complication compared to patients who waited longer.

Multimodal Imaging-Based Potential Visualization of the Tumor Microenvironment in Bone Metastasis

Bone metastasis (BM) is the most common malignant bone tumor and a significant cause of morbidity and mortality for patients with cancer. Compared to other metastatic organs, bone has unique characteristics in terms of the tumor microenvironment (TME). Precise assessments of the TME in BM could be an important step for developing an optimized management plan for patient care. Imaging approaches for BM have several advantages, such as biopsy not being required, multiple site evaluation, and serial assessment in the same sites. Owing to the developments of new imaging tracers or imaging modalities, bone TME could be visualized using multimodal imaging techniques. In this review, we describe the BM pathophysiology, diagnostic principles of major imaging modalities, and clinically available imaging modalities to visualize the TME in BM. We also discuss how the interactions between various factors affecting the TME could be visualized using multimodal imaging techniques.

Evolution of materials for implants in metastatic spine disease till date - Have we found an ideal material?

"Metastatic Spine Disease" (MSD) often requires surgical intervention and instrumentation with spinal implants. Ti6Al4V is widely used in metastatic spine tumor surgery (MSTS) and is the current implant material of choice due to improved biocompatibility, mechanical properties, and compatibility with imaging modalities compared to stainless steel. However, it is still not the ideal implant material due to the following issues. Ti6Al4V implants cause stress-shielding as their Young's modulus (110 gigapascal [GPa]) is higher than cortical bone (17-21 GPa). Ti6Al4V also generates artifacts on CT and MRI, which interfere with the process of postoperative radiotherapy (RT), including treatment planning and delivery. Similarly, charged particle therapy is hindered in the presence of Ti6Al4V. In addition, artifacts on CT and MRI may result in delayed recognition of tumor recurrence and postoperative complications. In comparison, polyether-ether-ketone (PEEK) is a promising alternative. PEEK has a low Young's modulus (3.6 GPa), which results in optimal load-sharing and produces minimal artifacts on imaging with less hinderance on postoperative RT. However, PEEK is bioinert and unable to provide sufficient stability in the immediate postoperative period. This issue may possibly be mitigated by combining PEEK with other materials to form composites or through surface modification, although further research is required in these areas. With the increasing incidence of MSD, it is an opportune time for the development of spinal implants that possess all the ideal material properties for use in MSTS. Our review will explore whether there is a current ideal implant material, available alternatives and whether these require further investigation.

Effects of Single-Dose Versus Hypofractionated Focused Radiation on Vertebral Body Structure and Biomechanical Integrity: Development of a Rabbit Radiation-Induced Vertebral Compression Fracture Model

PURPOSE

Vertebral compression fracture is a common complication of spinal stereotactic body radiation therapy. Development of an in vivo model is crucial to fully understand how focal radiation treatment affects vertebral integrity and biology at various dose fractionation regimens. We present a clinically relevant animal model to analyze the effects of localized, high-dose radiation on vertebral microstructure and mechanical integrity. Using this model, we test the hypothesis that fractionation of radiation dosing can reduce focused radiation therapy's harmful effects on the spine.

METHODS AND MATERIALS

The L5 vertebra of New Zealand white rabbits was treated with either a 24-Gy single dose of focused radiation or 3 fractionated 8-Gy doses over 3 consecutive days via the Small Animal Radiation Research Platform. Nonirradiated rabbits were used as controls. Rabbits were euthanized 6 months after irradiation, and their lumbar vertebrae were harvested for radiologic, histologic, and biomechanical testing.

RESULTS

Localized single-dose radiation led to decreased vertebral bone volume and trabecular number and a subsequent increase in trabecular spacing and thickness at L5. Hypofractionation of the radiation dose similarly led to reduced trabecular number and increased trabecular spacing and thickness, yet it preserved normalized bone volume. Single-dose irradiated vertebrae displayed lower fracture loads and stiffness compared with those receiving hypofractionated irradiation and with controls. The hypofractionated and control groups exhibited similar fracture load and stiffness. For all vertebral samples, bone volume, trabecular number, and trabecular spacing were correlated with fracture loads and Young's modulus (P < .05). Hypocellularity was observed in the bone marrow of both irradiated groups, but osteogenic features were conserved in only the hypofractionated group.

CONCLUSIONS

Single-dose focal irradiation showed greater detrimental effects than hypofractionation on the microarchitectural, cellular, and biomechanical characteristics of irradiated vertebral bodies. Correlation between radiologic measurements and biomechanical properties supported the reliability of this animal model of radiation-induced vertebral compression fracture, a finding that can be applied to future studies of preventative measures.

Clinical Therapy of Metastatic Spinal Tumors

Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.

The "Spinal Metastasis Invasiveness Index": A Novel Scoring System to Assess Surgical Invasiveness

STUDY DESIGN

Retrospective review.

OBJECTIVE

The aim of this study was to develop a surgical invasiveness index for metastatic spine tumor surgery (MSTS) that can serve as a standardized tool in predicting intraoperative blood loss and surgical duration; for the purpose of ascertaining resource requirements and aiding in patient education.

SUMMARY OF BACKGROUND DATA

Magnitude of surgery is important in the metastatic spine disease (MSD) population since these patients have a continuing postoperative oncological process; a consideration that must be taken into account to maintain or improve quality of life. Surgical invasiveness indices have been established for general spine surgery, adult deformity, and cervical deformity, but not yet for spinal metastasis.

METHODS

Demographic, oncological, and procedural data were collected from consecutive patients that underwent MSTS. Binary logistic regression, using median values for surgical duration and intraoperative estimated blood loss (EBL), was used to determine statistical significance of variables to be included in the "spinal metastasis invasiveness index" (SMII). The corresponding weightage of each of these variables was agreed upon by experienced spine surgeons. Multivariable regression analysis was used to predict operative time and EBL while controlling for demographical, procedural, and oncological characteristics.

RESULTS

Two hundred and sixty-one MSD patients were included with a mean age of 59.7-years and near equal sex distribution. The SMII strongly predicted extended surgical duration (R2 = 0.28, P < 0.001) and high intraoperative blood loss (R2 = 0.18, P < 0.001). When compared to a previously established surgical invasiveness index, the SMII accounted for more variability in the outcomes. For every unit increase in score, there was a 42-mL increase in mean blood loss (P < 0.001) and 5-minute increase in mean operative time (P < 0.001).

CONCLUSION

Long surgical duration and high blood loss were strongly predicted by the newly developed SMII. The use of the SMII may aid in preoperative risk assessment with the goal of improving patient outcomes and quality of life.Level of Evidence: 4.

Can Polyether Ether Ketone Dethrone Titanium as the Choice Implant Material for Metastatic Spine Tumor Surgery?

Instrumentation during metastatic spine tumor surgery (MSTS) provides stability to the spinal column in patients with pathologic fracture or iatrogenic instability produced while undergoing extensive decompression. Titanium is the current implant material of choice in MSTS. However, it hinders radiotherapy planning and generates artifacts, with magnetic resonance imaging and computed tomography scans used for postoperative evaluation of tumor recurrence and/or complications. The high modulus of elasticity of titanium (110 GPa) results in stress shielding, which may lead to construct failure at the bone-implant interface. Polyether ether ketone (PEEK), a thermoplastic polymer, is an emerging alternative to titanium for use in MSTS. The modulus of elasticity of PEEK (3.6 GPa) is close to that of cortical bone (17-21 GPa), resulting in minimal stress shielding. Its radiolucent and nonmetallic properties cause minimal interference with magnetic resonance imaging and computed tomography scans. PEEK also causes low-dose perturbation for radiotherapy planning. However, PEEK has reduced bioactivity with bone and lacks sufficient rigidity to be used as rods in MSTS. The reduced bioactivity of PEEK may be addressed by 1) surface modification (introducing porosity or bioactive coating with hydroxyapatite [HA] or titanium) and 2) forming composites with HA/titanium. The mechanical properties of PEEK may be improved by forming composites with HA or carbon fiber. Despite these modifications, all PEEK and PEEK-based implants are difficult to handle and contour intraoperatively. Our review provides a comprehensive overview of PEEK and modified PEEK implants, with a description of their properties and limitations, potentially serving as a basis for their future development and use in MSTS.

Readmission-Free Survival Analysis in Metastatic Spine Tumour Surgical Patients: A Novel Concept

BACKGROUND

Outcomes commonly used to ascertain success of metastatic spine tumour surgery (MSTS) are 30-day complications/mortality and overall/disease-free survival. We believe a new, effective outcome indicator after MSTS would be the absence of unplanned hospital readmission (UHR) after index discharge. We introduce the concept of readmission-free survival (ReAFS), defined as 'the time duration between hospital discharge after index operation and first UHR or death'. The aim of this study is to identify factors influencing ReAFS in MSTS patients.

PATIENTS AND METHODS

We retrospectively analysed 266 consecutive patients who underwent MSTS between 2005 and 2016. Demographics, oncological characteristics, procedural, preoperative and postoperative details were collected. ReAFS of patients within 2 years or until death was reviewed. Perioperative factors predictive of reduced ReAFS were evaluated using multivariate regression analysis.

RESULTS

Of 266 patients, 230 met criteria for analysis. A total of 201 had UHR, whilst 1 in 8 (29/230) had no UHR. Multivariate analysis revealed that haemoglobin ≥ 12 g/dL, ECOG score of ≤ 2, primary prostate, breast and haematological cancers, comorbidities ≤ 3, absence of preoperative radiotherapy and shorter postoperative length of stay significantly prolonged the time to first UHR.

CONCLUSIONS

Readmission-free survival is a novel concept in MSTS, which relies on patients' general condition, appropriateness of interventional procedures and underlying disease burden. Additionally, it may indicate the successful combination of a multi-disciplinary treatment approach. This information will allow oncologists and surgeons to identify patients who may benefit from increased surveillance following discharge to increase ReAFS. We envisage that ReAFS is a concept that can be extended to other surgical oncological fields.

An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

Neurological outcomes after surgery for spinal metastases in symptomatic patients: Does the type of decompression play a role? A comparison between different strategies in a 10-year experience

•

The achievement of a proper circumferential decompression of the sac instead of simple posterior bilateral laminectomy has been progressively highlighted.

•

Since the majority of spinal cord compression involves firstly the ventral part of the sac, circumferential and anterior decompression are associated with better neurological outcomes at discharge and at follow-up, and should be achieved in case of circumferential or anterior/anterolateral compression.

•

Post-operative improvement and/or maintenance of ambulation resulted to be a significative protective factor at last follow-up.

Introduction

The impact of neurological deficits plays a role of inestimable importance in patients with a neoplastic disease. The role of surgery for the management of symptomatic spinal cord compression (SSCC) cannot be overemphasized, as surgery represents often the first and paramount step in patients presenting with motor deficits. The traditional paradigm of simple bilateral laminectomy for the treatment of spinal cord compression has been reviewed. The need to achieve a proper circumferential decompression of the spinal sac has been progressively highlighted in combination with the development of the more comprehensive and multidisciplinary concept of separation surgery.

Objective

The aim of this paper is to analyze different strategies of decompression, while evaluating whether circumferential/anterior decompression is able to guarantee a better control and restoration of neurological functions in patients with motor impairment, if compared to traditional posterior decompression.

Materials and methods

This is a retrospective observational study investigating symptomatic patients that underwent surgical treatment for spinal metastases at author’s Institutions from January 2010 to June 2019. Data recorded concerned patient demographics, tumor histology, peri-operative and follow-up neurological status (ASIA), ambulation ability, stability (SINS), grade (ESCC) and source of epidural compression and type of decompression (anterior/anterior-lateral (AD); posterior/posterior-lateral (PD/PDL); circumferential (CD)).

Results

A total number of 84 patients was included. AD/CD patients showed higher chance of neurological improvement and reduced rates of worsening compared to PD/PLD group (94.1%/100% vs 60.4%; 11.8% vs 45.8% respectively). Univariate logistic regression identified immediate post-operative improvement to be a significative protective factor for worsening at last follow-up. Stratifying patients for site of compression and considering anterior and circumferential groups, immediate post-operative neurological improvement, was mostly associated with AD and CD (p 0.011 and 0.025 respectively). Walking at last follow up was influenced by post-operative maintenance of ambulation (p 0.001).

Conclusion

The necessity to remove the epidural metastatic compression from its source should be considered of paramount importance. Since the majority of spinal cord compression involves firstly the ventral part of the sac, CD/AD are associated with better neurological outcomes and should be achieved in case of circumferential or anterior/anterolateral compression.

Symptomatic Construct Failure after Metastatic Spine Tumor Surgery

Study Design

Retrospective cohort study.

Purpose

To evaluate the incidence and presentation of symptomatic failures (SFs) after metastatic spine tumor surgery (MSTS). To identify the associated risk factors. To categorize SFs based on the management in these patients.

Overview of Literature

Few studies have reported on the incidence (1.9%–16%) and risk factors of SF after MSTS. It is unclear whether all SFs, occurring in MSTS-patients, result in revision surgery.

Methods

We conducted a retrospective analysis on 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological SF were defined as presentation before and after 3 months from index surgery, respectively. Univariate and multivariate models of competing risk regression analysis were designed to determine the risk factors for SF with death as a competing event.

Results

We observed 14 SFs (5.7%) in 246 patients; 10 (4.1%) underwent revision surgery. Median survival was 13.4 months. The mean age was 58.8 years (range, 21–87 years); 48.4% were women. The median time to failure was 5 months (range, 1–60 months). Patients with SF were categorized into three groups: (1) SF when the primary implant was revised (n=5, 35.7%); (2) peri-construct progression of disease requiring extension (n=5, 35.7%); and (3) SFs that did not warrant revision (n=4, 28.5%). Four patients (28.5%) presented with early failure. SF commonly occurred at the implant-bone interface (9/14) and all patients had a spinal instability neoplastic score (SINS) >7. Thirteen patients (92.8%) who developed failure had fixation spanning junctional regions. Multivariate competing risk regression showed that preoperative Eastern Cooperative Oncology Group score was a significant risk factor for implant failure (adjusted sub-hazard ratio, 7.0; 95% confidence interval, 1.63–30.07; p<0.0009).

Conclusions

The incidence of SF (5.7%) was low in patients undergoing MSTS although these patients did not undergo spinal fusion. Preoperative ambulators involved a 7 times higher risk of failure than non-ambulators. Preoperative SINS >7 and fixations spanning junctional regions were associated with SF. Majority of construct failures occurred at the implant-bone interface.

Asymptomatic Construct Failure after Metastatic Spine Tumor Surgery: A New Entity or a Continuum with Symptomatic Failure?

Study Design

Retrospective cohort study.

Purpose

To study the incidence, onset, underlying mechanism, clinical course, and factors leading to asymptomatic construct failure (AsCF) after metastatic spinal tumor surgery (MSTS).

Overview of Literature

The reported incidence rates for implant and/or construct failure after MSTS are low (1.9%–16%) and based on clinical presentations and revisions required for symptomatic failures (SFs). AsCF after MSTS has not been reported.

Methods

We conducted a retrospective analysis of 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological AsCF were defined as presentation before and after 3 months, respectively. We analyzed patients with AsCF for risk factors and survival duration by performing competing risk regression analyses where AsCF was the event of interest, with SF and death as competing events.

Results

We observed AsCF in 41/246 patients (16.7%). The mean time to onset of AsCF after MSTS was 2 months (range, 1–9 months). Median survival of patients with AsCF was 20 and 41 months for early and late failures, respectively. Early AsCF accounted for 80.5% of cases, while late AsCF accounted for 19.5%. The commonest radiologically detectable AsCF mechanism was angular deformity (increase in kyphus) in 29 patients. Increasing age (p<0.02) and primary breast (13/41, 31.7%) (p<0.01) tumors were associated with higher AsCF rates. There was a non-significant trend towards AsCF in patients with a spinal instability neoplastic score ≥7, instrumentation across junctional regions, and construct lengths of 6–9 levels. None of the patients with AsCF underwent revision surgery.

Conclusions

AsCF after MSTS is a distinct entity. Most patients with early AsCF did not require intervention. Patients who survived and maintained ambulation for longer periods had late failure. Increasing age and tumors with a better prognosis have a higher likelihood of developing AsCF. AsCF is not necessarily an indication for aggressive/urgent intervention.

In the Extraordinary Times of Coronavirus Disease 2019: Clinical Strategies for Performing Spinal Surgery

The coronavirus disease 2019 (COVID-19) pandemic has caused pronounced strain on global healthcare systems, forcing the streamlining of clinical activities and conservation of health resources. There is a pressing need for institutions to present discipline-specific strategies for the management of COVID-19 patients. We present the comprehensive considerations at the National University Hospital, Singapore from the surgeon’s and anesthetist’s perspectives in the performance of spinal surgery in COVID-19 patients. These are based on national guidelines and overarching principles of protection for the healthcare workers (HCWs) and efficiency in surgical planning. The workflow begins with the emergency department screening that has been adapted to the local epidemiology of COVID-19 in order to identify suspected/confirmed cases. If patient history cannot be obtained, demographic, clinical, and imaging data are used. Designated orthopedic “contaminated teams” are available 24/7 with an activation time of <30 minutes for review. In cases where sub-specialty spine surgeons were required, these professionals were inducted into the “contaminated team” and quarantined until cleared to return to work. Indications for emergency spine surgery were determined pre-emptively. Preoperative surgical considerations included the minimization of manpower, limited dissection, reduced operative time, and judicious use of equipment, leading to reduced aerosolization. Anesthesia considerations include preoperative screening for COVID-19–related concerns that influence surgery, operating room process planning and induction, intraoperative, reversal, recovery, and resuscitation considerations. Focused multi-disciplinary preoperative briefing facilitates familiarization. Surgical, anesthetic, and postoperative workflows were designed to reduce the risk of transmission and protect HCWs while effectively performing spinal surgery. The COVID-19 pandemic has necessitated paradigm shifts in healthcare planning, hospital workflows, and operative protocols. The viral burden does not discriminate between surgeons and physicians, and it is crucial that we, as medical professionals, adapt practices to be malleable and fluid to address the ever-changing developments.

Vacuum-Assisted Closure: An Effective Technique to Manage Wound Complications After Metastatic Spine Tumour Surgery (MSTS)-A Case Report

The management of wound complications following metastatic spine tumor surgery (MSTS) remains a formidable task. Plastic coverage procedures after MSTS are challenging due to unhealthy donor sites following previous radiotherapy and prolonged nonambulation. Negative pressure wound therapy (NPWT) is usually not recommended after MSTS due to fear of tumor seeding and excessive blood loss. However, in certain patients post-MSTS, who may be considered as receiving palliative treatment, NPWT can be effective in managing wound complications. We describe our initial experience with the use of NPWT in a 57-year-old lady diagnosed with multiple lumbar and cervicothoracic vertebral metastases secondary to non-small cell lung carcinoma. She underwent 2 cycles of preoperative radiotherapy followed by decompression and posterior instrumentation of lumbosacral and cervicothoracic regions succeeded by another cycle of radiotherapy. The patient developed wound dehiscence and poly-microbial surgical site infection that was not responsive to regular debridements and antibiotics. Hence, we applied NPWT as an alternative treatment to plastic surgical procedures. The patient clinically improved with a reduced quantity of wound discharge, increased granulation tissue, and a downward trend in the inflammatory markers. Subsequently, wound was secondarily closed after 14 days. The patient was discharged after a total hospital stay of 41 days. The intravenous antibiotics (piperacillin/tazobactam) were changed to oral (ciprofloxacin) after 6 weeks and continued for 4 months. The patient survived for 3 years without any wound complications. Our case report suggests that NPWT can be a potential treatment option for managing wound complications following MSTS.

[Minimally invasive spinal surgery: stages of development]

In recent decades, spinal surgery has changed significantly. The active use of modern knowledge of anatomy, various diagnostic modules, specialized surgical equipment and high-tech tools has made it possible to transform classical surgical techniques into a new area of spinal neurosurgery - minimally invasive spine surgery (MISS). Its main goals are to reduce damage to the skin and adjacent tissues, significantly reduce the level of pain, reduce the duration of inpatient treatment and fully restore functional status in the shortest possible time. This article reflects the main criteria for MISS compliance and types of surgical interventions, provides information on the advantages of minimally invasive surgical technologies and their possible disadvantages. Currently, the use of MISS is observed in all areas of vertebrology - for degenerative diseases, tumors, inflammatory and traumatic lesions of the spine. At the same time, minimizing surgical aggression while maximizing the achievement of goal becomes the main rule of modern spinal surgery.

Decision Making in Patients With Metastatic Spine. The Role of Minimally Invasive Treatment Modalities

Spine metastases affect more than 70% of terminal cancer patients that eventually suffer from severe pain and neurological symptoms. Nevertheless, in the overwhelming majority of the cases, a spinal metastasis represents just one location of a diffuse systemic disease. Therefore, the best practice for treatment of spinal metastases depends on many different aspects of an oncological disease, including the assessment of neurological status, pain, location, and dissemination of the disease as well as the ability to predict the risk of disease progression with neurological worsening, benefits and risks associated to treatment and, eventually, expected survival. To address this need for a framework and algorithm that takes all aspects of care into consideration, we reviewed available evidence on the multidisciplinary management of spinal metastases. According to the latest evidence, the use of stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT) for spinal metastatic disease is rapidly increasing. Indeed, aggressive surgical resection may provide the best results in terms of local control, but carries a significant rate of post-surgical morbidity whose incidence and severity appears to be correlated to the extent of resection. The multidisciplinary management represents, according to current evidence, the best option for the treatment of spinal metastases. Noteworthy, according to the recent literature evidence, cases that once required radical surgical resection followed by low-dose conventional radiotherapy, can now be more effectively treated by minimally invasive spinal surgery (MISS) followed by spine SRS with decreased morbidity, improved local control, and more durable pain control. This combination allows also extending this standard of care to patients that would be too sick for an aggressive surgical treatment.

Open Kyphoplasty for Metastatic Spine Disease: A Retrospective Clinical Series

OBJECTIVE

Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer.

METHODS

Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up.

RESULTS

Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P < 0.0001). Median follow-up was 16 months and overall survival 22 months.

CONCLUSIONS

OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.

Surgical management of sternoclavicular joint septic arthritis

INTRODUCTION

Infections of the sternoclavicular joint (SCJ) account for less than 1% of all joint infections. There are no standardized diagnostic and therapeutic algorithms defined in literature. This study intended to report the risk factors, the bacterial spectrum, the extent and localization and the clinical outcome of SCJ infections.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of 13 patients (8 men, five women, mean age 37.6 years) with SCJ infections between Januray 1st 2008 and October 30th 2015 for clinical parameters and radiological studies. All patients were interviewed during their follow-up along with clinical examination and assessing the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH).

RESULTS

Nine patients presented with local chest pain and swelling; in 4 patients, the prevalent symptom was pain without local signs of inflammation. Full blood count revealed a mean leukocytosis of 15 × 10⁹ L and a mean CRP of 21.0 mg/dl. Approximately 61.5% reported known diabetes mellitus. 10 patients presented an involvement of surrounding structures. All patients received a preoperativ CT scan. Each patient was treated via SCJ resection without intraoperative complications. Primary wound closure was possible in all cases. The mean follow-up was 95 days. Wound culture revealed Staphylococcus aureus in all patients. Pathological examination affirmed acute osteomyelitis in 7 patients. Four patients required the intensive care of which 2 patients died from septic shock. Recurrent infection was encountered in 3 patients who underwent revision surgery. Mean DASH Score was 18.7.

CONCLUSION

CT should be routinely obtained to recognize the possible extends to the surrounding structures. SCJ resection can result in satisfactory clinical results and should be considered in cases of extended infections including the surrounding structures. Empiric antibiotic coverage should contain cephalosporin or extended-spectrum penicillin. Inappropriate or less-invasive surgical procedures may cause recurrencent infections, especially in cases of osteomyelitis.

Spinal Metastasis of Well-Differentiated Liposarcoma Component in Retroperitoneal Dedifferentiated Liposarcoma Treated by Minimally Invasive Surgery

Case

Generally, well-differentiated liposarcoma (WDL) has recurrence potential but lacks metastatic potential. We present a rare case of spinal metastasis of WDL component in retroperitoneal dedifferentiated liposarcoma (DDL) treated by tumor curettage and L1 laminectomy followed by percutaneous pedicle screw fixation. Histological examination showed metastasis of the WDL component of DDL. The patient was ambulatory until death.

Conclusion

To our knowledge, no case of spinal metastasis of WDL component in retroperitoneal DDL has been reported. We should carefully consider characteristics of DDLs during treatment. Minimally invasive surgery may be a powerful tool in patients with spinal metastasis.