Agreement in the assessment of metastatic spine disease using scoring systems

Management of vertebral metastases in the cervico-occipital junction

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or anterolateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumor. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms are an indication for surgery.

[Translated article] Management of vertebral metastases in the cervico-occipital junction

Occipito-cervical metastases correspond to 0.5% of spinal metastases. The management of these lesions is complex and involves multiple radiological studies, such as simple radiology, computed tomography (CT), magnetic resonance imaging (MRI). Is vascular involvement is suspected, tests to assess vascular permeability are also recommended (angioCT). This type of lesion, due to its complex location, may require different types of approaches, commonly it will be the posterior approach, but sometimes anterior or antero-lateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumour. Pain with head turning can guide us to the diagnosis in an unstable spine. Magnetic resonance is the test of choice to diagnose and study these lesions. The presence of instability or progressive neurological symptoms is an indication for surgery.

The Management of Metastatic Spinal Cord Compression in Routine Clinical Practice

(1) Background: Whether clinical management of spinal metastatic disease (SMD) matches evidence-based recommendations is largely unknown. (2) Patients and Methods: A questionnaire was distributed through Spanish Medical Societies, exploring routine practice, interpretation of the SINS and ESCC scores and agreement with items in the Tokuhashi and SINS scales, and NICE guideline recommendations. Questionnaires were completed voluntarily and anonymously, without compensation. (3) Results: Eighty specialists participated in the study. A protocol for patients with SMD existed in 33.7% of the hospitals, a specific multidisciplinary board in 33.7%, 40% of radiological reports included the ESCC score, and a prognostic scoring method was used in 73.7%. While 77.5% of the participants were familiar with SINS, only 60% used it. The different SINS and ESCC scores were interpreted correctly by 57.5-70.0% and 30.0-37.5% of the participants, respectively. Over 70% agreed with the items included in the SINS and Tokuhashi scores and with the recommendations from the NICE guideline. Differences were found across private/public sectors, hospital complexity, number of years of experience, number of patients with SMD seen annually and especially across specialties. (4) Conclusions: Most specialists know and agree with features defining the gold standard treatment for patients with SCC, but many do not apply them.

A Comparison of Prognostic Models to Facilitate Surgical Decision-Making for Patients With Spinal Metastatic Disease

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Compare the performance of and provide cutoff values for commonly used prognostic models for spinal metastases, including Revised Tokuhashi, Tomita, Modified Bauer, New England Spinal Metastases Score (NESMS), and Skeletal Oncology Research Group model, at three- and six-month postoperative time points.

SUMMARY OF BACKGROUND DATA

Surgery may be recommended for patients with spinal metastases causing fracture, instability, pain, and/or neurological compromise. However, patients with less than three to six months of projected survival are less likely to benefit from surgery. Prognostic models have been developed to help determine prognosis and surgical candidacy. Yet, there is a lack of data directly comparing the performance of these models at clinically relevant time points or providing clinically applicable cutoff values for the models.

MATERIALS AND METHODS

Sixty-four patients undergoing surgery from 2015 to 2022 for spinal metastatic disease were identified. Revised Tokuhashi, Tomita, Modified Bauer, NESMS, and Skeletal Oncology Research Group were calculated for each patient. Model calibration and discrimination for predicting survival at three months, six months, and final follow-up were evaluated using the Brier score and Uno's C, respectively. Hazard ratios for survival were calculated for the models. The Contral and O'Quigley method was utilized to identify cutoff values for the models discriminating between survival and nonsurvival at three months, six months, and final follow-up.

RESULTS

Each of the models demonstrated similar performance in predicting survival at three months, six months, and final follow-up. Cutoff scores that best differentiated patients likely to survive beyond three months included the Revised Tokuhashi score=10, Tomita score=four, Modified Bauer score=three, and NESMS=one.

CONCLUSION

We found comparable efficacy among the models in predicting survival at clinically relevant time points. Cutoff values provided herein may assist surgeons and patients when deciding whether to pursue surgery for spinal metastatic disease.

LEVEL OF EVIDENCE

4.

Metastatic Versus Osteoporotic Vertebral Fractures on MRI: A Blinded, Multicenter, and Multispecialty Observer Agreement Evaluation

BACKGROUND

MRI is assumed to be valid for distinguishing metastatic vertebral fractures (MVFs) from osteoporotic vertebral fractures (OVFs). This study assessed (1) concordance between the image-based diagnosis of MVF versus OVF and the reference (biopsy or follow-up of >6 months), (2) interobserver and intraobserver agreement on key imaging findings and the diagnosis of MVF versus OVF, and (3) whether disclosing a patient's history of cancer leads to variations in diagnosis, concordance, or agreement.

PATIENTS AND METHODS

This retrospective cohort study included clinical data and imaging from 203 patients with confirmed MVF or OVF provided to 25 clinicians (neurosurgeons, radiologists, orthopedic surgeons, and radiation oncologists). From January 2018 through October 2018, the clinicians interpreted images in conditions as close as possible to routine practice. Each specialist assessed data twice, with a minimum 6-week interval, blinded to assessments made by other clinicians and to their own previous assessments. The kappa statistic was used to assess interobserver and intraobserver agreement on key imaging findings, diagnosis (MVF vs OVF), and concordance with the reference. Subgroup analyses were based on clinicians' specialty, years of experience, and complexity of the hospital where they worked.

RESULTS

For diagnosis of MVF versus OVF, interobserver agreement was fair, whereas intraobserver agreement was substantial. Only the latter improved to almost perfect when a patient's history of cancer was disclosed. Interobserver agreement for key imaging findings was fair or moderate, whereas intraobserver agreement on key imaging findings was moderate or substantial. Concordance between the diagnosis of MVF versus OVF and the reference was moderate. Results were similar regardless of clinicians' specialty, experience, and hospital category.

CONCLUSIONS

When MRI is used to distinguish MVF versus OVF, interobserver agreement and concordance with the reference were moderate. These results cast doubt on the reliability of basing such a diagnosis on MRI in routine practice.

Prediction Accuracy of Common Prognostic Scoring Systems for Metastatic Spine Disease: Results of a Prospective International Multicentre Study of 1469 Patients

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVE

To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems.

METHODS

We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival.

RESULTS

All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66.

CONCLUSION

No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation.

LEVEL OF EVIDENCE

3.

Surgically treated spinal metastases: Do prognostic scores have a role?

Background:

The outcome for patients with metastatic disease in spine is difficult to predict. Multiple scoring systems were utilized in this study to determine their effectiveness in predicting long-term prognoses.

Methods:

A retrospective analysis of surgically treated patients of spinal metastasis was performed between 2005 and 2016. Data were collected prospectively during which 8 patients were lost to follow-up. Ultimately, data from 63 patients were reviewed. Treatment and prognoses were analyzed utilizing various scoring systems including the SINS, the Tomita, the modified Tokouhashi and Bauer scores.

Results:

Records of 63 patients, averaging 54 years of age, were analyzed. The Tomita score was applied in 44 patients, a modified Bauer score was studied in 49 patients, while SINS and modified Tokouhashi scores were calculated in all 63 patients. The hazard ratios for the Tomita score were 1, 0.030, 0.622, and 0.272, respectively. The hazard ratios for the modified Bauer scores were 1, 4.663, and 1.622, respectively. The Tokouhashi ratios were 1, 1.656, and 0.501, respectively. Of interest, the Tomita scores provided the highest statistical significance (P = 0.000) followed by the Bauer (P = 0.002) and Tokuhashi scores (P = 0.003). Notably, the SINS score showed no significant correlation in predicting patient survival.

Conclusion:

For evaluating the metastatic spine disease, this study evaluated the prognostic efficacy of four widely used scores: the Tomita, score, the modified Tokouhashi and Bauer scores, and the SINS scores. The Tomita scores provided the highest statistical significance, followed by the Bauer, and Tokuhashi scores, while the SINS score showed no significant correlation in predicting patient survival.

Is multidetector computed tomography comparable to magnetic resonance imaging for assessment of lumbar foraminal stenosis?

Background Both multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are used for assessment of lumbar foraminal stenosis (LFS). Therefore, it is relevant to assess agreement between these imaging modalities. Purpose To determine intermodality, inter-, and intra-observer agreement for assessment of LFS on MDCT and MRI. Material and Methods A total of 120 foramina in 20 patients who visited our institution in January and February 2014 were evaluated by six radiologists with different levels of experience. Radiologists evaluated presence and severity of LFS on sagittal CT and MR images according to a previously published LFS grading system. Intermodality agreement was analyzed by using weighted kappa statistics, while inter- and intra-observer agreement were analyzed by using intraclass correlation coefficients (ICCs) and kappa statistics. Results Overall intermodality agreement was moderate to good (kappa, 0.478-0.765). In particular, two professors and one fellow tended to overestimate the degree of LFS on CT compared with MRI. For inter-observer agreement of all six observers, ICCs indicated excellent agreement for both CT (0.774) and MRI (0.771), while Fleiss' kappa values showed moderate agreement for CT (0.482) and MRI (0.575). There was better agreement between professors and fellows compared with residents. For intra-observer agreement, ICCs indicated excellent agreement, while kappa values showed good to excellent agreement for both CT and MRI. Conclusion MDCT was comparable to MRI for diagnosis and assessment of LFS, especially for experienced observers. However, there was a tendency to overestimate the degree of LFS on MDCT compared with MRI.

Who are the Best Candidates for Decompressive Surgery and Spine Stabilization in Patients With Metastatic Spinal Cord Compression?: A New Scoring System

STUDY DESIGN

A retrospective study.

OBJECTIVE

This study aims to develop a new scoring system that can guild surgeons to select the best candidates for decompressive surgery in patients with metastatic spinal cord compression (MSCC).

SUMMARY OF BACKGROUND DATA

Predicting survival and functional outcome is essential when selecting the individual treatment for patients with MSCC. The criteria for identifying MSCC patients who are most likely to benefit from decompressive surgery remain unclear.

METHODS

We retrospectively analyzed 12 preoperative characteristics for postoperative survival in a series of 206 patients with MSCC who were operated with decompressive surgery and spine stabilization. Characteristics significantly associated with survival in the multivariate analysis were included in the scoring system. Postoperative function outcome was also analyzed on the basis of the scoring system.

RESULTS

According to the multivariate analysis, primary site (P < 0.01), preoperative ambulatory status (P < 0.01), visceral metastases (P < 0.01), preoperative chemotherapy (P = 0.02), and bone metastasis at cancer diagnosis (P = 0.03) had a significant impact on postoperative survival and were included in the scoring system. According to the prognostic scores, which ranged from 0 to 10 points, three risk groups were designed: 0 to 2, 3 to 5, and 6 to 10 points. The corresponding 6 months survival rates were 8.2%, 56.5%, and 91.5%, respectively (P < 0.01), and postoperative ambulatory rates were 35.7%, 73.3%, and 95.9%, respectively (P < 0.01).

CONCLUSION

We present a new scoring system for predicting survival and function outcome of MSCC patients after surgical decompression and spine stabilization. This new scoring system can help surgeons select the best candidates for surgical treatment.

LEVEL OF EVIDENCE

4.

Reliability of a spinal metastasis prognostic score to model 1-year survival

BACKGROUND

Predicting survival after surgery for patients with metastatic spine disease can be challenging, with multiple variables that can influence a patient's overall survival. Predictive models have been developed to assist clinicians in providing a prognosis for patients. Recently, Ghori et al. reported a composite model taking into account a modified Bauer score, preoperative albumin, and ambulatory status of patients with spinal metastasis. Using an independent cohort, we sought to assess the reliability and validity of this composite model to predict 1-year survival in patients diagnosed with metastatic cancer to the spine.

PURPOSE

This study aimed to assess the reliability and validity of the Ghori et al. composite model to predict 1-year survival in patients diagnosed with metastatic cancer to the spine, using an independent cohort.

STUDY DESIGN/SETTING

A retrospective study was carried out.

PATIENT SAMPLE

The sample comprised 161 patients with spinal metastasis undergoing surgery.

OUTCOME MEASURES

Patients' modified Bauer score, preoperative albumin, and ambulatory status were assessed.

METHODS

This study used a retrospective analysis of 161 patients with spinal metastasis who underwent surgical management from 2007 to 2013. The ability of this composite model to predict 1-year survival was compared with actual patient survival using multivariable logistic regression to control for confounders, as well as post-regression diagnostics.

RESULTS

Our analysis revealed significantly lower 1-year mortality among patients with higher composite scores as compared with those with lower scores. Strong associations between scores and survival were appreciated in unadjusted analysis. The final model was able to account for 80% of the variation in the 1-year survival, and there was no evidence of lack of fit.

CONCLUSION

This study demonstrates, in an independent cohort of spinal metastases patients, that a composite model taking into account the ambulatory status, serum albumin, and modified Bauer score is able to better predict postoperative survival. These data serve to validate the use of this predictive model in determining the prognosis of patients with spinal metastasis.