Reliability of the spinal instability neoplastic scale among radiologists: an assessment of instability secondary to spinal metastases

Automated vertebrae identification and segmentation with structural uncertainty analysis in longitudinal CT scans of patients with multiple myeloma

OBJECTIVES

Optimize deep learning-based vertebrae segmentation in longitudinal CT scans of multiple myeloma patients using structural uncertainty analysis.

MATERIALS & METHODS

Retrospective CT scans from 474 multiple myeloma patients were divided into train (179 patients, 349 scans, 2005-2011) and test cohort (295 patients, 671 scans, 2012-2020). An enhanced segmentation pipeline was developed on the train cohort. It integrated vertebrae segmentation using an open-source deep learning method (Payer's) with a post-hoc structural uncertainty analysis. This analysis identified inconsistencies, automatically correcting them or flagging uncertain regions for human review. Segmentation quality was assessed through vertebral shape analysis using topology. Metrics included 'identification rate', 'longitudinal vertebral match rate', 'success rate' and 'series success rate' and evaluated across age/sex subgroups. Statistical analysis included McNemar and Wilcoxon signed-rank tests, with p < 0.05 indicating significant improvement.

RESULTS

Payer's method achieved an identification rate of 95.8% and success rate of 86.7%. The proposed pipeline automatically improved these metrics to 98.8% and 96.0%, respectively (p < 0.001). Additionally, 3.6% of scans were marked for human inspection, increasing the success rate from 96.0% to 98.8% (p < 0.001). The vertebral match rate increased from 97.0% to 99.7% (p < 0.001), and the series success rate from 80.0% to 95.4% (p < 0.001). Subgroup analysis showed more consistent performance across age and sex groups.

CONCLUSION

The proposed pipeline significantly outperforms Payer's method, enhancing segmentation accuracy and reducing longitudinal matching errors while minimizing evaluation workload. Its uncertainty analysis ensures robust performance, making it a valuable tool for longitudinal studies in multiple myeloma.

Advancing Metastatic Spine Tumor Research: A Review of AO Spine Knowledge Forum Tumor's Scientific Contributions Derived From the EPOSO Network, 2014-2024

Study DesignNarrative Review.ObjectivesTo summarize the work of the AO Spine Knowledge Forum Tumor, specifically studies from the Epidemiology, Process and Outcomes in Spine Oncology (EPOSO) study.MethodsA narrative review of all published manuscripts from the EPOSO study was undertaken. EPOSO represents a multicenter, prospective registry effort across 10 North American and European sites to enroll patients with metastatic disease of the spine.ResultsThe current review summarized all studies from the EPOSO network, divided into the following five sections: (1) quality of life and satisfaction, (2) overall survival, (3) spinal instability, (4) neurologic outcome in patients with metastatic epidural spinal cord compression or radicular pain, and (5) patient and tumor-specific factors. Several important findings were elucidated. Patient evaluation should include SINS, nutritional status, severity and duration of neurologic deficit, extent of metastatic tumor burden, and differentiation of axial from radicular pain. Moreover, SOSGOQ2.0 serves as a useful and validated instrument for patient-reported outcome instrument. Despite the palliative nature of metastatic spine surgery, clear improvement in quality-of-life is seen. Even in patients with short-survival, the remaining weeks and months of life result in improved quality-of-life. Metastatic spine surgery often improves neurologic function, potentially enhancing survival through increased performance status.ConclusionsSeveral noteworthy results have come from the EPOSO network, highlighting important trends in metastatic spine care. The AO Spine Knowledge Forum Tumor has helped advancing metastatic spine tumor research as well as ensure these new findings reach and benefit clinicians and their patients.

Impact of Fixation Length for Single-Level Spinal Metastasis Surgery in the Elderly: A Multicenter Study

Purpose Spinal metastases are common and affect most patients with metastatic cancer. Surgery is crucial for managing symptoms such as pain and paralysis but carries a high risk of complications, especially in the elderly. This study aimed to investigate the impact of short versus long fixation on outcomes mainly focused on surgery-related complications in elderly patients ≥60 years old undergoing surgery for single-level spinal metastasis. Methods This study is a retrospective multicenter cohort study. We retrospectively analyzed data from 153 patients who underwent spinal metastasis surgery between 2014 and 2023, focusing on 44 patients aged ≥60 years with single-level lesions. Out of 151 patients, those under 60 years old, those who underwent only decompression surgery, and those with missing data were excluded, resulting in a final inclusion of 44 patients. Patients were divided into short fusion (four or fewer vertebrae) and long fusion (five or more vertebrae) groups. This study aims to compare the impact of short (four or fewer vertebrae) versus long (five or more vertebrae) spinal fixation on surgical and patient-centered outcomes in elderly patients undergoing surgery for single-level spinal metastasis. Patients' demographics, surgical details, and complications were compared between the groups. Results The study included 44 patients: long fusion group (n = 24) and short fusion group (n = 20). No significant between-group differences were found in demographics or surgery-related factors. Minimally invasive surgery was performed in 29.2% of long fusion group patients and 10% of short fusion group patients, but this difference was not statistically significant. Survival analysis showed no significant difference in median survival between the groups (short fusion group = 29 months vs. long fusion group = 26 months, P = 0.533). Mortality rates were also similar between groups during the follow-up period. The short fusion group had a higher rate of surgical complications (45% vs. 12.5%, P = 0.021) and more frequent postoperative complications (55% vs. 29.2%, P=0.125), although the difference was not statistically significant. Conclusion This study found no significant difference in survival rates between short and long fixation in elderly patients undergoing surgery for single-level spinal metastasis. In spinal metastasis surgery, extending the fixation range may be considered if necessary.

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

STUDY DESIGN

Systematic review.

OBJECTIVE

In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries.

METHODS

Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications.

RESULTS

Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation.

CONCLUSION

In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Surgical options for metastatic spine tumors: WFNS spine committee recommendations

Surgical treatments for metastatic spine tumors have evolved tremendously over the last decade. Improvements in immunotherapies and other medical treatments have led to longer life expectancy in cancer patients. This, in turn, has led to an increase in the incidence of metastatic spine tumors. Spine metastases remain the most common type of spine tumor. In this study, we systematically reviewed all available literature on metastatic spine tumors and spinal instability within the last decade. We also performed further systematic reviews on cervical metastatic tumors, thoracolumbar metastatic tumors, and minimally invasive surgery in metastatic spine tumors. Lastly, the results from the systematic reviews were presented to an expert panel at the World Federation of Neurosurgical Societies (WFNS) meeting, and their consensus was also presented.

Measuring the Delay in the Referral of Unstable Vertebral Metastasis to the Spine Surgeon: A Retrospective Study in a Latin American Institution

Background

The delay in the referral of patients with potential surgical vertebral metastasis (VM) to the spine surgeon is strongly associated with a worse outcome. The spinal instability neoplastic score (SINS) allows for determining the risk of instability of a spine segment with VM; however, it is almost exclusively used by specialists or residents in neurosurgery or orthopedics. The objective of this work is to report the delay in surgical consultation of patients with potentially unstable and unstable VM (SINS >6) at our center.

Material

We performed a 5-year single-center retrospective analysis of patients with spine metastasis on computed tomography (CT). Patients were divided into Group 1 (G1), potentially unstable VM (SINS 7-12), and Group 2 (G2), unstable VM (SINS 13-18). Time to surgical referral was calculated as the number of days between the report of the VM in the CT and the first clinical assessment of a spinal surgeon on the medical records.

Results

We analyzed 220 CT scans, and 98 met the selection criteria. Group 1 had 85 patients (86.7%) and Group 2 had 13 (13.3%). We observed a mean time to referral of 83.5 days in the entire cohort (std = 127.6); 87.6 days (std = 135.1) for G1, and 57.2 days (std = 53.8) for G2. The delay in referral showed no significant correlation with the SINS score.

Conclusion

We report a mean delay of 83.5 days in the surgical referral of VM (SINS >6, n = 98). Both groups showed cases of serious referral delay, with 25% of patients having the first surgical consultation more than three months after the CT study.

Advances in the management of spinal metastases: what the radiologist needs to know

Spine is the most frequently involved site of osseous metastases. With improved disease-specific survival in patients with Stage IV cancer, durability of local disease control has become an important goal for treatment of spinal metastases. Herein, we review the multidisciplinary management of spine metastases, including conventional external beam radiation therapy, spine stereotactic radiosurgery, and minimally invasive and open surgical treatment options. We also present a simplified framework for management of spinal metastases used at The University of Texas MD Anderson Cancer Center, focusing on the important decision points where the radiologist can contribute.

Puntajes V

El Comité Editorial quiere brindar a los lectores de la RAAOT una actualización de las escalas de uso corriente. El empleo de tablas y escalas es una práctica muy extendida en la ortopedia y traumatología. La medición y la cuantificación de los aspectos clínicos, funcionales y radiográficos se convirtieron en una herramienta imprescindible para la toma de decisiones en diferentes aspectos de la actividad asistencial. Llevamos a cabo una revisión de las escalas más utilizadas, definimos su uso e incluimos bibliografía original y actualizada.Nivel de Evidencia: V

Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression

Metastatic Spinal Cord Compression (MSCC) is a debilitating complication in oncology patients. This narrative review discusses the strengths and limitations of various imaging modalities in diagnosing MSCC, the role of imaging in stereotactic body radiotherapy (SBRT) for MSCC treatment, and recent advances in deep learning (DL) tools for MSCC diagnosis. PubMed and Google Scholar databases were searched using targeted keywords. Studies were reviewed in consensus among the co-authors for their suitability before inclusion. MRI is the gold standard of imaging to diagnose MSCC with reported sensitivity and specificity of 93% and 97% respectively. CT Myelogram appears to have comparable sensitivity and specificity to contrast-enhanced MRI. Conventional CT has a lower diagnostic accuracy than MRI in MSCC diagnosis, but is helpful in emergent situations with limited access to MRI. Metal artifact reduction techniques for MRI and CT are continually being researched for patients with spinal implants. Imaging is crucial for SBRT treatment planning and three-dimensional positional verification of the treatment isocentre prior to SBRT delivery. Structural and functional MRI may be helpful in post-treatment surveillance. DL tools may improve detection of vertebral metastasis and reduce time to MSCC diagnosis. This enables earlier institution of definitive therapy for better outcomes.

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

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

Preliminary establishment of a spinal stability scoring system for multiple myeloma

BACKGROUND

Multiple myeloma is an incurable malignant plasma cell disorder that represents the most common primary malignant bone tumor. It commonly involves bone metastasis in multiple vertebral bodies, and the Spinal Instability Neoplastic Score scoring system may not be fully applicable to multiple myeloma (MM) patients.

AIM

To evaluate the spinal stability of patients with MM spinal involvement to guide their clinical treatment.

METHODS

By using the Delphi method, we collected and extracted information through a series of questionnaires and improved it via feedback. We also preliminarily established a spinal stability scoring system for multiple myeloma.

RESULTS

Fifteen clinicians completed a second round of questionnaires and compared their answers with those of the first round of questionnaires to identify significant comments or changes that required group discussions. As a result, no further feedback was used to improve the scoring system. After integrating the information from the expert consultation questionnaire, we established the initial scoring system for MM spine stability and used the scoring system to assess a series of representative clinical cases. The MM spinal stability scoring system was created by calculating the scores of the six separate components: location, pain, number of segments, physiological curvature, comorbidities, and neurological function. The minimum value was “0”, and the maximum value was “24”. A score of “0–10” indicated “spine stability”, a score of “11–17” indicated “potential instability”, and a score of “18–24” indicated “spine instability”. Patients with a score of “11–24” need an intervention such as surgery.

CONCLUSION

The initial establishment of the MM spine stability scoring system provides a vital theoretical basis for the evaluation of spine stability in individuals with MM.

Interrater and Intrarater Reliability of the Vertebral Bone Quality Score

BACKGROUND

Vertebral bone quality had a significant impact on postoperative outcomes in spinal fusion surgery. New magnetic resonance imaging-based measures, such as the Vertebral Bone Quality (VBQ) score, may allow for bone quality assessment without the radiation associated with conventional testing. In the present study, we sought to assess the intrarater and interrater reliability of VBQ scores calculated by medical professionals and trainees.

METHODS

Thirteen reviewers of various specialties and levels of training were recruited and asked to calculate VBQ scores for 30 patients at 2 time points separated by 2 months. Scored volumes were acquired from patients treated for both degenerative and oncologic indications. Intrarater and interrater agreement, quantified by intraclass correlation coefficient (ICC), was assessed using 2-way random effects modeling. Square-weight Cohen κ and Kendall Tau-b were used to determine whether raters assigned similar scores during both evaluations.

RESULTS

All raters showed moderate to excellent reliability for VBQ score (ICC 0.667-0.957; κ0.648-0.921) and excellent reliability for all constituent components used to calculate VBQ score (ICC all ≥0.97). Interrater reliability was also found to be good for VBQ score on both the first (ICC = 0.818) and second (ICC = 0.800) rounds of assessment; scores for the constituent component all had ICC values ≥0.97 for the constituent components.

CONCLUSIONS

The VBQ score appears to have both good intrarater and interrater reliability. In addition, there appeared to be no correlation between score reliability and level of training. External validation and further investigations of its ability to accurately model bone biomechanical properties are necessary.

An analysis of tumor-related potential spinal column instability (Spine Instability Neoplastic Scores 7-12) eventually requiring surgery with a 1-year follow-up

OBJECTIVE

Within the Spine Instability Neoplastic Score (SINS) classification, tumor-related potential spinal instability (SINS 7-12) may not have a clear treatment approach. The authors aimed to examine the proportion of patients in this indeterminate zone who later required surgical stabilization after initial nonoperative management. By studying this patient population, they sought to determine if a clear SINS cutoff existed whereby the spine is potentially unstable due to a lesion and would be more likely to require stabilization.

METHODS

Records from patients treated at the University of California, San Francisco, for metastatic spine disease from 2005 to 2019 were retrospectively reviewed. Seventy-five patients with tumor-related potential spinal instability (SINS 7-12) who were initially treated nonoperatively were included. All patients had at least a 1-year follow-up with complete medical records. A univariate chi-square test and Student t-test were used to compare categorical and continuous outcomes, respectively, between patients who ultimately underwent surgery and those who did not. A backward likelihood multivariate binary logistic regression model was used to investigate the relationship between clinical characteristics and surgical intervention. Recursive partitioning analysis (RPA) and single-variable logistic regression were performed as a function of SINS.

RESULTS

Seventy-five patients with a total of 292 spinal metastatic sites were included in this study; 26 (34.7%) patients underwent surgical intervention, and 49 (65.3%) did not. There was no difference in age, sex, comorbidities, or lesion location between the groups. However, there were more patients with a SINS of 12 in the surgery group (55.2%) than in the no surgery group (44.8%) (p = 0.003). On multivariate analysis, SINS > 11 (OR 8.09, CI 1.96-33.4, p = 0.004) and Karnofsky Performance Scale (KPS) score < 60 (OR 0.94, CI 0.89-0.98, p = 0.008) were associated with an increased risk of surgery. KPS score was not correlated with SINS (p = 0.4). RPA by each spinal lesion identified an optimal cutoff value of SINS > 10, which were associated with an increased risk of surgical intervention. Patients with a surgical intervention had a higher incidence of complications on multivariable analysis (OR 2.96, CI 1.01-8.71, p = 0.048).

CONCLUSIONS

Patients with a mean SINS of 11 or greater may be at increased risk of mechanical instability requiring surgery after initial nonoperative management. RPA showed that patients with a KPS score of 60 or lower and a SINS of greater than 10 had increased surgery rates.

Surgical management of spinal metastases involving the cervicothoracic junction: results of a multicenter, European observational study

OBJECTIVE

Surgical management of spinal metastases at the cervicothoracic junction (CTJ) is highly complex and relies on case-based decision-making. The aim of this multicentric study was to describe surgical procedures for metastases at the CTJ and provide guidance for clinical and surgical management.

METHODS

Patients eligible for this study were those with metastases at the CTJ (C7-T2) who had been consecutively treated in 2005-2019 at 7 academic institutions across Europe. The Spine Instability Neoplastic Score, neurological function, clinical status, medical history, and surgical data for each patient were retrospectively assessed. Patients were divided into four surgical groups: 1) posterior decompression only, 2) posterior decompression and fusion, 3) anterior corpectomy and fusion, and 4) anterior corpectomy and 360° fusion. Endpoints were complications, surgical revision rate, and survival.

RESULTS

Among the 238 patients eligible for inclusion this study, 37 were included in group 1 (15%), 127 in group 2 (53%), 18 in group 3 (8%), and 56 in group 4 (24%). Mechanical pain was the predominant symptom (79%, 189 patients). Surgical complications occurred in 16% (group 1), 20% (group 2), 11% (group 3), and 18% (group 4). Of these, hardware failure (HwF) occurred in 18% and led to surgical revision in 7 of 8 cases. The overall complication rate was 34%. In-hospital mortality was 5%.

CONCLUSIONS

Posterior fusion and decompression was the most frequently used technique. Care should be taken to choose instrumentation techniques that offer the highest possible biomechanical load-bearing capacity to avoid HwF. Since the overall complication rate is high, the prevention of in-hospital complications seems crucial to reduce in-hospital mortality.

Predictive Value of the Spinal Instability Neoplastic Score for Survival and Ambulatory Function After Surgery for Metastatic Spinal Cord Compression in 110 Patients with Prostate Cancer

STUDY DESIGN

We retrospectively analyzed Spinal Instability Neoplastic Score (SINS) in 110 patients with prostate cancer operated for metastatic spinal cord compression (MSCC).

OBJECTIVE

We aimed to investigate the association between SINS and clinical outcomes after surgery for MSCC in patients with prostate cancer.

SUMMARY OF BACKGROUND DATA

The SINS is a useful tool for assessing tumor-related spinal instability, but its prognostic value regarding survival and neurological outcome is still controversial.

METHODS

We analyzed 110 consecutive patients with prostate cancer who underwent surgery for MSCC. The patients were categorized according to their SINS. Patients with castration-resistant prostate cancer (CRPC, n = 84) and those with hormone-naïve disease (n = 26) were analyzed separately.

RESULTS

In total, 106 of 110 patients met the SINS criteria for potential instability or instability (scores 7-18). The median SINS was 10 (range 6-15) for patients with CRPC and 9 (7-16) for hormone-naïve patients. In the CRPC group, the SINS was classified as stable (score 0-6) in 4 patients, as potentially unstable (score 7-12) in 70 patients, and as unstable (score 13-18) in 10 patients. In the hormone-naïve group, 22 patients met the SINS criteria for potential instability and 4 patients for instability. There was no statistically significant difference in the overall risk for death between the SINS potentially unstable and unstable categories (adjusted hazard ratio 1.3, P = 0.4), or in the risk of loss of ambulation 1 month after surgery (adjusted odds ratio 1.4, P = 0.6).

CONCLUSION

The SINS is helpful in assessing spinal instability when selecting patients for surgery, but it does not predict survival or neurological outcomes. Patients with a potential spinal instability benefit equally from surgery for MSCC as do patients with spinal instability.Level of Evidence: 3.

Accuracy and precision of the spinal instability neoplastic score (SINS) for predicting vertebral compression fractures after radiotherapy in spinal metastases: a meta-analysis

Radiotherapy has played an important role in the treatment of spinal metastases. One of the major complications of radiotherapy is vertebral compression fracture (VCF). Although the spinal instability neoplastic score (SINS) was developed for evaluating spinal instability in patients with spinal metastases, it is also commonly used to predict VCF after radiotherapy in patients with spinal metastases. However, its accuracy for predicting radiotherapy-induced VCF and precision remain controversial. The aim of this study was to clarify the diagnostic value of the SINS to predict radiotherapy-induced VCF and to make recommendations for improving its diagnostic power. We searched core databases and identified 246 studies. Fourteen studies were analyzed, including 7 studies (with 1269 segments) for accuracy and 7 studies (with 280 patients) for precision. For accuracy, the area under the summary receiver operating characteristic curve was 0.776. When a SINS cut-off value of 7 was used, as was done in the included studies, the pooled sensitivity was 0.790 and the pooled specificity was 0.546. For precision, the summary estimate of interobserver agreement was the highest dividing 2 categories based on a cut-off value of 7, and the value was 0.788. The body collapse showed moderate relationship and precision with the VCF. The lytic tumor of bone lesion showed high accuracy and fair reliability, while location had excellent reliability, but low accuracy. The SINS system can be used to predict the occurrence of VCF after radiotherapy in spinal metastases with moderate accuracy and substantial reliability. Increasing the cut-off value and revising the domains may improve the diagnostic performance to predict the VCF of the SINS.

[Radiologic diagnosis of pathologic fractures]

BACKGROUND

Pathologic fractures are fractures that occur without an adequate traumatic event due to focal benign or malignant skeletal lesions. The most common causes of pathologic fractures are cystic bone lesions, plasmocytoma or multiple myeloma, and the development of osseous metastases, which is increasing due to an aging general population and advances in cancer treatment. The differentiation of pathologic fractures from stress fractures, especially osteoporotic insufficiency fractures is crucial for correct treatment planning.

OBJECTIVES

This review intends to explain the imaging characteristics of pathologic fractures. Moreover, it explains the role of imaging when pathologic fractures are suspected. In addition, the Mirels' score and the SINS (Spinal Instability Neoplastic Score), which are powerful yet easy-to-use tools for the assessment of the fracture risk of benign or malignant bony lesions of the extremities and the vertebral column, shall be introduced.

MATERIALS AND METHODS

A PubMed literature search with the following terms was conducted: "pathologic fracture", "fatigue fracture", "insufficiency fracture", "treatment of pathologic fractures", "imaging of pathologic fractures", "fracture risk", "bone metastases", "MRI of pathologic fractures", "CT of pathologic fractures", "differentiation of pathologic and insufficiency fractures", "Mirels' score", "SINS" and "spinal instability neoplastic score".

RESULTS

The definitions of pathologic, fatigue, and insufficiency fractures are explained. Moreover, the role of imaging in the clinical workup of suspected pathologic fractures and the differentiation of pathologic fractures from fatigue or insufficiency fractures as well as common scoring systems to assess the fracture risk of pathologic fractures are described.

The Role of Palliative Radiotherapy in the Treatment of Spinal Bone Metastases from Head and Neck Tumors-A Multicenter Analysis of a Rare Event

This retrospective multi-center analysis aimed to assess the clinical response and stabilizing effects of palliative radiotherapy (RT) for spinal bone metastases (SBM) in head and neck cancer (HNC), and to establish potential predictive factors for stability and overall survival (OS). Patients included in this analysis were treated at the University Hospitals of Mainz, Freiburg, and Heidelberg between 2001 and 2019. Clinical information was taken from the medical records. The stability of affected vertebral bodies was assessed according to the validated spine instability neoplastic score (SINS) based on CT-imaging before RT, as well as 3 and 6 months after RT. OS was quantified as the time between the start of palliative RT and death from any cause or last follow-up. Potential predictive factors for stability and OS were analyzed using generalized estimating equations and Cox regression for time-varying covariates to take into account multiple observations per patient. The mean follow-up time of 66 included patients after the first palliative RT was 8.1 months (range 0.3–85.0 months). The majority of patients (70%; n = 46) had squamous cell carcinomas (SCC) originating from the pharynx, larynx and oral cavity, while most of the remaining patients (26%; n = 17) suffered from salivary glands tumors. A total of 95 target volumes including 178 SBM were evaluated that received a total of 81 irradiation series. In patients with more than one metastasis per irradiated region, only the most critical bone metastasis was analyzed according to the SINS system. Prior to RT, pain and neurologic deficits were present in 76% (n = 72) and 22% (n = 21) of irradiated lesions, respectively, and 68% of the irradiated lesions (n = 65) were assessed as unstable or potentially unstable prior to RT. SBM-related pain symptoms and neurologic deficits responded to RT in 63% and 47% of the treated lesions, respectively. Among patients still alive at 3 and 6 months after RT with potentially unstable or unstable SBM, a shift to a better stability class according to the SINS was observed in 20% and 33% of the irradiated SBM, respectively. Pathological fractures of SBM were frequently detected before the start of irradiation (43%; n = 41), but after RT, new fractures or increasing vertebral body sintering within the irradiated region occurred rarely (8%; n = 8). A pathological fracture before RT was negatively associated with stabilization 6 months after RT (OR 0.1, 95% CI 0.02–0.49, p = 0.004), while a Karnofsky performance score (KPS) ≥ 70% was associated positively with a stabilization effect through irradiation (OR 6.09, 95% CI 1.68–22.05, p = 0.006). Mean OS following first palliative RT was 10.7 months, and the KPS (≥70% vs. <70%) was shown to be a strong predictive factor for OS after RT (HR 0.197, 95% CI 0.11–0.35, p < 0.001). There was no significant difference in OS between patients with SCC and non-SCC. Palliative RT in symptomatic SBM of HNC provides sufficient symptom relief in the majority of patients, while only about one third of initially unstable SBM show re-stabilization after RT. Since patients in our multi-center cohort exhibited very limited OS, fractionation schemes should be determined depending on the patients’ performance status.

The Incidence and Management Trends of Metastatic Spinal Tumors in South Korea: A Nationwide Population-based Study

STUDY DESIGN

Population-based study. From 2008 to 2017, data from the national database of the Korean Health Insurance Review & Assessment Service were analyzed. The national insurance system and all medical expense bill data of the entire population are included in the database.

OBJECTIVE

The aim of this study was to elucidate the incidence and management trends of metastatic spinal tumors in South Korea.

SUMMARY OF BACKGROUND DATA

The spine is the most common location of bone metastases. However, population-based studies in this topic are limited.

METHODS

The International Classification of Disease, 10th revision, medical behavior, and examination codes were used to identify the incidence and management trends of metastatic spinal tumors. The Cochran-Armitage trend test was used in statistical analysis.

RESULTS

Overall, 38,007 patients (average age, 61 years) diagnosed with metastatic spinal tumors were analyzed. Metastatic tumors were most common in patients in their 60s (25.7%). The 10-year incidence of spinal metastases in South Korea was 6.68 cases per 100,000 population. The age-adjusted incidence per 100,000 population decreased from 8.16 cases in 2008 to 6.18 in 2017 (P = 0.03). Sex-adjusted incidence rates in men increased from 8.60 per 100,000 persons in 2008 to 8.70 in 2017 (P < 0.001); those of women decreased from 8.20 per 100,000 persons in 2008 to 4.15 in 2017 (P < 0.05). The most common primary tumor site was the lung (26.9%), followed by the breast (16.9%), prostate (10.8%), and liver (8.1%). Radiation therapy was constant at about 3500 cases per annum (P = 0.62); surgical treatment increased from 1158 to 1382 cases (P < 0.001). Resection and instrumentation surgeries increased significantly (P < 0.001), whereas cementation decreased continuously. Total healthcare costs increased significantly from $19,925,296 in 2008 to $30,268,217 in 2017 (P < 0.001).

CONCLUSION

The incidence of metastatic spinal tumors decreased in South Korea. Resection and instrumentation procedures increased, and total healthcare costs increased rapidly.

LEVEL OF EVIDENCE

3.

Is the Spinal Instability Neoplastic Score Accurate and Reliable in Predicting Vertebral Compression Fractures for Spinal Metastasis? A Systematic Review and Qualitative Analysis

Spinal metastases can present with varying degrees of mechanical instability. The Spinal Instability Neoplastic Score (SINS) was developed as a tool to assess spinal neoplastic-related instability while helping to guide referrals among oncology specialists. Some previous papers suggested that the SINS was accurate and reliable, while others disagreed with this opinion. We performed a systematic review regarding the SINS to evaluate its accuracy and precision in predicting vertebral compression fractures (VCFs). The 21 included studies investigated a total of 2118 patients. Thirteen studies dealt with the accuracy of SINS to predict post-radiotherapy VCFs, and eight dealt with the precision. Among 13 studies, 11 agreed that the SINS categories showed statistically significant accuracy in predicting VCF. Among eight studies, body collapse was effective for predicting VCFs in six studies, and alignment and bone lesion in two studies. Location has no statistical significance in predicting VCFs in any of the eight studies. The precision of SINS categories was substantial to excellent in six of eight studies. Among the six components of the SINS, the majority of the included studies reported that location showed near perfect agreement; body collapse, alignment, and posterolateral involvement showed moderate agreement; and bone lesion showed fair agreement. Bone lesion showed significant accuracy in predicting VCFs in half of eight studies, but displayed fair reliability in five of seven studies. Although location was indicated as having near perfect reliability, the component showed no accuracy for predicting VCFs in any of the studies and deleting or modifying the item needs to be considered. The SINS system may be accurate and reliable in predicting the occurrence of post-radiotherapy VCFs for spinal metastasis. Some components seem to be substantially weak and need to be revised.

Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment

OBJECTIVE

Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes.

METHODS

In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model.

RESULTS

Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy.

CONCLUSIONS

At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.

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.

Outcomes for Vertebrectomy for Malignancy and Correlation to the Spine Instability Neoplastic Score (SINS): a 10-Year Single-Center Perspective

OBJECTIVE

The clinical prognostic value of the Spinal Instability Neoplastic Score (SINS), in the context of vertebrectomy for neoplasia, has not yet been established. This retrospective study of 134 patients aims to evaluate the efficacy of the SINS to predict outcomes and survival after vertebrectomy for malignancy.

METHODS

The patients were classified into 2 groups: indeterminate stability (SINS 7-12) and unstable (SINS 13-18). Outcomes assessed included survival days after procedure, neurological function (modified Frankel grade), operative time, blood loss, complications, construct failure, and length of inpatient stay.

RESULTS

The indeterminate group included 68 patients, whereas the unstable group included 66 patients. No patients were classified as stable (SINS 0-6). The median survival was 225 days (interquartile range, 81-522 days). There was a statistically significant difference (P < 0.001) in survival days after vertebrectomy between the indeterminate group (435 days) and the unstable group (126 days). The majority of patients (119) had a favourable Frankel grade after procedure with no significant difference between SINS groups (P = 0.534). There were no differences in the operative time (234 vs. 210; P = 0.130), inpatient hospital length of stay (10 days vs. 11 days; P = 0.152), complications, or need for intensive care admission (intensive care unit) between the 2 cohorts. There was a statistically significant difference (P = 0.006) for intraoperative blood loss between the indeterminate group (1400 mL) and the unstable group (850 mL).

CONCLUSIONS

This study demonstrates a statistically significant increased survival in the indeterminate cohort. These results demonstrate the potential ability of the SINS to act as a clinical prognostic tool with regard to survival time.

Importance of Spinal Alignment in Primary and Metastatic Spine Tumors

Spinal alignment, particularly with respect to spinopelvic parameters, is highly correlated with morbidity and health-related quality-of-life outcomes. Although the importance of spinal alignment has been emphasized in the deformity literature, spinopelvic parameters have not been considered in the context of spine oncology. Because the aim of oncologic spine surgery is mostly palliative, consideration of spinopelvic parameters could improve postoperative outcomes in both the primary and metastatic tumor population by taking overall vertebral stability into account. This review highlights the relevance of focal and global spinal alignment, particularly related to spinopelvic parameters, in the treatment of spine tumors.

Intra- and interobserver reliability of the Spinal Instability Neoplastic Score system for instability in spine metastases: a systematic review and meta-analysis

Mechanical instability is one of the two main indications for surgical intervention in patients with metastatic spine disease. Since its publication in 2010, the Spinal Instability Neoplastic Score (SINS) has been the most commonly used means of assessing mechanical instability. To prove clinically valuable though, diagnostic tests must demonstrate consistency across measures and across observers. Here we report a systematic review and meta-analysis of all prior reports of intraobserver and interobserver reliability of the SINS score. To identify articles, we queried the PubMed, CINAHL, EMBASE, Cochrane, and Web of Science databases for all full-text English articles reporting interobserver or intraobserver reliability for the SINS score, category, or a domain of the SINS score. Articles reporting confidence intervals for these metrics were then subjected to meta-analysis to identify pooled estimates of reliability. Of 167 unique studies identified, seven met inclusion criteria and were subjected to qualitative review and meta-analysis. Intraobserver reliability for SINS score was found to be near perfect [estimate =0.815; 90% CI (0.661-0.969)] and interobserver reliability was substantial [0.673; (0.227-1.12)]. Intraobserver and interobserver reliability among spine surgeons was significantly better than reliability across all observers (both P<0.0001). Qualitative analysis suggested that increased surgeon experience may be associated with greater intraobserver and interobserver reliability among spine surgeons. On the whole, meta-analysis of the available literature suggests SINS to have good intraobserver and interobserver reliability, giving it the potential to be a valuable guide to the management of patients with spinal metastases. Further research is required to demonstrate that SINS score correlates with the clinical decision to stabilize.

Instability and impending instability in patients with vertebral metastatic disease

Metastatic disease commonly involves the spine with an increasing incidence due to a worldwide rise of cancer incidence and a longer survival of patients with osseous metastases. Metastases compromise the mechanical integrity of the vertebra and make it susceptible to fracture. Patients with pathological vertebral fracture often become symptomatic, with mechanical pain generally due to intervertebral instability, and may develop spinal cord compression and neurological deficits. Advances in imaging, radiotherapy, as well as in spinal surgery techniques, have allowed the evolution from conventional palliative external beam radiotherapy to modern stereotactic radiosurgery and from traditional open surgery to less-invasive, and sometimes prophylactic stabilization surgical treatments. It is therefore clear that fracture risk prediction, and maintenance or restoration of intervertebral stability, are important objectives in the management of these patients. Correlation between imaging findings and clinical manifestations is crucial, and a common knowledge base for treatment team members rather than a compartmentalized view is very important. This article reviews the literature on the imaging and clinical diagnosis of intervertebral instability and impending instability in the setting of spine metastatic disease, including the spinal instability neoplastic score, which is a reliable tool for diagnosing unstable or potentially unstable metastatic spinal lesions, and on the different elements considered for treatment.

Prognosis of Single Spinal Metastatic Tumors: Predictive Value of the Spinal Instability Neoplastic Score System for Spinal Adverse Events

STUDY DESIGN

This was a retrospective cohort study.

PURPOSE

We evaluated the predictive value of the Spinal Instability Neoplastic Score (SINS) system for spinal adverse events (SAEs) in patients with single spinal metastatic tumor.

OVERVIEW OF LITERATURE

The SINS system was developed to assess spinal instability in patients with single metastatic spinal tumor. However, the system's potential predictive value for SAEs has been partially studied.

METHODS

This system was applied to a retrospective cohort of 78 patients with single spinal metastatic tumors. The patients underwent surgical treatment and were postoperatively followed up for at least 2 years or until death. The attribution of each score and total SINS to SAE (vertebral compression fracture [VCF] and spinal cord compression [SCC]) occurrence was assessed using the Cox proportional hazards model.

RESULTS

SAEs occurred on average 7 months after diagnosis of spinal metastasis. The mean survival rate post diagnosis was 43 months. Multivariate analysis using the Cox proportional hazards model revealed that the pain (p =0.029) and spinal alignment (p =0.001) scores were significantly related to VCF occurrence, whereas the pain (p =0.008) and posterolateral involvement (p =0.009) scores were related to SCC occurrence.

CONCLUSIONS

Among the components of the SINS system, while pain and spinal alignment showed a significant association with VCF occurrence, pain and posterolateral involvement showed association with SCC occurrence.

Outcomes and Prognosis of Neurological Decompression and Stabilization for Spinal Metastasis: Is Assessment with the Spinal Instability Neoplastic Score Useful for Predicting Surgical Results?

Study Design

Retrospective study.

Purpose

To evaluate the efficacy of the Spinal Instability Neoplastic Score (SINS) in predicting surgical outcomes and survival. Patients were categorized into two groups according to the SINS, and their surgical outcomes and survival following decompression and stabilization were assessed.

Overview of Literature

Palliative surgery in patients with a life expectancy ≥3 months may effectively improve their overall condition in the long term. Currently, the effectiveness of the SINS for predicting surgical results and survival remains controversial.

Methods

This study included 44 patients who underwent decompression and stabilization for spinal metastases at Yokosuka Kyosai Hospital between 2008 and 2017. The patients were divided into two groups: stable (SINS ≤12) and unstable (SINS ≥13). Changes in the Frankel score and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) were compared between the two groups, and patient survival was evaluated according to the SINS, Tokuhashi score, and Katagiri score.

Results

The stable group (SINS range, 7–12) included 24 patients while the unstable group (SINS range, 13–16) included 20 patients. The Frankel score significantly improved from 2.8 to 3.6 in the stable group (p <0.001) and from 2.7 to 3.9 in the unstable group (p <0.001). The ECOG-PS significantly improved from 3.2 to 2.1 in the stable group (p <0.001) and from 3.0 to 1.8 in the unstable group (p <0.001). There was a statistically significant difference in median survival between the two groups.

Conclusions

All patients treated with palliative surgery showed favorable outcomes, as indicated by improved the Frankel score and ECOG-PS following surgery. However, median survival was significantly better in the stable group. The results of this study indicate that the SINS is appropriate for surgical decision making and may be used to predict survival.

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

STUDY DESIGN

Narrative review.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management - spinal metastases

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

Management of extranodal lymphoma of the spine: a study of 30 patients

Extranodal lymphoma of the spine is often a late manifestation of systemic disease, and may result in symptoms of pain, neurologic compromise or spinal instability. Symptomatic relief is generally achieved by radiotherapy alone, but is not sufficient in addressing spinal instability. The indications for surgery remain controversial, but may be required for spinal stabilization, or refractory disease. Currently, there is a lack of studies that compare the indications and clinical outcomes of patients receiving surgical and nonsurgical management of spinal extranodal lymphoma. Medical records of 30 patients seen from March 2006 to August 2015, with histologically confirmed spinal lymphoma, were retrospectively reviewed. Demographic information, clinical factors, imaging, treatment and clinical outcomes were recorded. 19 patients were treated surgically and 11 nonsurgically (i.e., chemotherapy, radiation or combination). Surgery was performed for emergent neurological deterioration, mechanical stabilization, refractoriness to medical management or to perform an open biopsy for pathological diagnosis. Among those treated surgically, significantly fewer patients could carry on normal activities (KPS <70) at baseline, compared with those treated nonsurgically. However, there were no significant differences regarding pain medication use, functional status at 1 year, or mean survival (87.6 months) between groups. Surgery for extranodal lymphoma may be required in specific cases, resulting in favorable and similar outcomes compared with nonsurgical management.

Analysis of the Relationship Between the Epidural Spinal Cord Compression (ESCC) Scale and Paralysis Caused by Metastatic Spine Tumors

STUDY DESIGN

A retrospective, single-institute, and radiographic study.

OBJECTIVE

To evaluate the relationship between the epidural spinal cord compression (ESCC) scale and the severity of metastatic spine tumor-induced paralysis.

SUMMARY OF BACKGROUND DATA

The ESCC scale is used to evaluate the grade of spinal cord compression on T2-weighted magnetic resonance imaging (MRI). However, few studies have investigated the relationship between such MRI findings and paralysis.

METHODS

The subjects were 467 patients with metastatic spine tumors and grade 1b or worse spinal cord compression according to the ESCC scale. Evaluations using this scale were performed by three spine surgeons, and results that were obtained by two or more surgeons were adopted. We also examined patients whose spinal cord compression deteriorated by one grade or more to American Spinal Injury Association (ASIA) grade C or worse within the first 3 weeks after MRI.

RESULTS

The kappa coefficients for inter- and intraexaminer variability were 0.90 and 0.95, respectively. ASIA grade D or worse paralysis developed in at least 50% of the patients with ESCC grade 1b or worse spinal cord compression at the C1-T2 and at least 50% of those with ESCC grade 1c or worse spinal cord compression at the T3-L5. The frequency of ASIA grade C or worse paralysis was high among the patients with ESCC grade 2 or worse spinal cord compression at the C7-L1. Nineteen patients experienced rapid deterioration of one grade or more to ASIA grade C or worse paralysis within the first 3 weeks after MRI. Of these, paralysis occurred in at least 30% of the patients with anterolateral or circumferential cord compression combined with ESCC grade 2 or 3 compression at the C7-L1.

CONCLUSION

The severity of paralysis was not correlated with the ESCC scale. Patients with anterolateral or circumferential ESCC grade 2 or 3 cord compression at the C7-L1 are at high risk of rapidly progressive paralysis.

LEVEL OF EVIDENCE

4.

The Role of the Size and Location of the Tumors and of the Vertebral Anatomy in Determining the Structural Stability of the Metastatically Involved Spine: a Finite Element Study

Vertebral fractures associated with the loss of structural integrity of neoplastic vertebrae are common, and determined to the deterioration of the bone quality in the lesion area. The prediction of the fracture risk in metastatically involved spines can guide in deciding if preventive solutions, such as medical prophylaxis, bracing, or surgery are indicated for the patient. In this study, finite element models of 22 thoracolumbar vertebrae were built based on CT scans of three spines, covering a wide spectrum of possible clinical scenarios in terms of age, bone quality and degenerative features, taking into account the local material properties of bone tissue. Simulations were performed in order to investigate the effect of the size and location of the tumoral lesion, the bone quality and the vertebral level in determining the structural stability of the neoplastic vertebrae. Tumors with random size and positions were added to the models, for a total of 660 simulations in which a compressive load was simulated. Results highlighted the fundamental role of the tumor size, whereas the other parameters had a lower, but non-negligible impact on the axial collapse of the vertebra, the vertebral bulge in the transverse plane and the canal narrowing under the application of the load. All the considered parameters are radiologically measurable, and can therefore be translated in a straightforward way to the clinical practice to support decisions about preventive treatment of metastatic fractures.

ABCs of the degenerative spine

Degenerative changes in the spine have high medical and socioeconomic significance. Imaging of the degenerative spine is a frequent challenge in radiology. The pathogenesis of this degenerative process represents a biomechanically related continuum of alterations, which can be identified with different imaging modalities. The aim of this article is to review radiological findings involving the intervertebral discs, end plates, bone marrow changes, facet joints and the spinal canal in relation to the pathogenesis of degenerative changes in the spine. Findings are described in association with the clinical symptoms they may cause, with a brief review of the possible treatment options. The article provides an illustrated review on the topic for radiology residents.

TEACHING POINTS

• The adjacent vertebrae, intervertebral disc, ligaments and facet joints constitute a spinal unit. • Degenerative change is a response to insults, such as mechanical or metabolic injury. • Spine degeneration is a biomechanically related continuum of alterations evolving over time.

Impact of the Spinal Instability Neoplastic Score on Surgical Referral Patterns and Outcomes

Background

The Spinal Instability Neoplastic Score (sins) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of sins in a population-based cohort of patients undergoing palliative spine radiotherapy (rt) and referral rates to spinal surgery pre-rt. Secondary outcomes included referral to a spine surgeon post-rt, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events.

Methods

We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student's t-test, Chi-squared, Fisher's exact, and Kaplan-Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups.

Results

We included 195 patients with a follow-up of 6.1 months. The median sins was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-rt referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-rt with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups.

Conclusion

Higher sins was associated with pre-rt referral to a spine surgeon, but most patients with high sins were not referred. Higher sins was not associated with shorter survival or worse outcome following rt.

Assessing the utility of the spinal instability neoplastic score (SINS) to predict fracture after conventional radiation therapy (RT) for spinal metastases

PURPOSE

Assessing the stability of spinal metastases is critical for making treatment decisions. The spinal instability neoplastic score (SINS) was developed by the Spine Oncology Study Group to categorize tumor-related lesions; however, data describing its utility in predicting fractures in patients with spinal metastases are limited. The purpose of this study is to assess the validity of SINS in predicting new or worsening fracture after radiation therapy (RT) to spine metastases.

METHODS AND MATERIALS

This is a retrospective analysis of patients treated with conventional RT alone (median total dose, 30 Gy; range, 8-47 Gy; median number of fractions, 10; range, 1-25) for spinal metastasis at Dana-Farber/Brigham and Women's Cancer Center from 2006 to 2013. SINS was calculated for each lesion (range, 0-18). The primary endpoint was time from RT start to radiographically documented new or worsening fracture or last disease assessment.

RESULTS

A total of 203 patients and 250 lesions were included in analysis. The percentages of lesions with SINS of 0 to 6, 7 to 12, and 13 to 18 were 38.8%, 54.8%, and 6.4%, respectively. Of 250 lesions, 20.4% developed new or worsening fractures; 14.4% for SINS 0 to 6, 21.2% for SINS 7 to 12, and 50.0% for SINS 13 to 18. Multivariate analysis adjusted for sex, age, Eastern Cooperative Oncology Group, histology, and total dose indicated that, compared with stable lesions (SINS 0-6), potentially unstable lesions (SINS 7-12) demonstrated a greater likelihood of new or worsening fracture that was not statistically significant (hazard ratio, 1.66; 95% confidence interval, 0.85-3.22; P = .14), and unstable lesions (SINS 13-18) were significantly more likely to develop to new or worsening fracture (hazard ratio, HR,4.37, 95% confidence interval, 1.80-10.61; P = .001).

CONCLUSIONS

In this study of patients undergoing RT for spinal metastases, 20.4% developed new or worsening vertebral fractures. SINS is demonstrated to be a useful tool to assess fracture risk after RT.

Patient-reported outcomes after surgical stabilization of spinal tumors: symptom-based validation of the Spinal Instability Neoplastic Score (SINS) and surgery

BACKGROUND CONTEXT

Neoplastic spinal instability is movement-related pain or neurologic compromise under physiologic loads with the Spinal Instability Neoplastic Score (SINS) developed to facilitate diagnosis. There is a paucity of evidence that mechanical instability correlates with patient-reported symptoms and that surgical stabilization significantly improves these patient-reported outcomes (PROs).

PURPOSE

The objective of this study was to determine if SINS correlates with patient-reported preoperative pain and disability, and if surgical stabilization significantly improves PRO.

STUDY DESIGN

A single-institution prospective cohort study was carried out.

PATIENT SAMPLE

A total of 131 patients who underwent stabilization for metastatic spinal tumor treatment between July 2014 and August 2016 were included.

OUTCOMES MEASURES

Preoperative baseline and mean difference in perioperative PROs as assessed by the Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory (MDASI) were the outcome measures.

METHODS

The SINS was analyzed as a continuous, ordinal, and categorical variable (Stable: 0-6, Indeterminate: 7-12, Unstable: 13-18). Statistical analysis was performed using Spearman rank coefficient (rho), the Kruskal-Wallis test, and an extension of the Cochran-Armitage trend test. The SINS and association between the mean differences in post- and preoperative PRO scores was analyzed using the Wilcoxon signed-rank test.

RESULTS

There was a statistically significant positive correlation between increasing SINS and severity of preoperative pain with BPI average pain (rho=0.20; p=.03) and MDASI pain (rho=0.19; p=.03). Increasing SINS correlated with severity of preoperative disability with BPI walking (rho=0.19; p=.04), MDASI activity (rho=0.24; p=.006), and MDASI walking (rho=0.20; p=.03). Similar associations were noted when SINS was analyzed as an ordinal categorical variable. Stabilization significantly improved nearly all PRO measures for patients with indeterminate and unstable SINS. Significant correlations persisted when controlling for neurologic status and were not affected based on the technique of surgical stabilization used.

CONCLUSIONS

Patient-related outcome-based validation of SINS confirms this scoring system for diagnosing neoplastic spinal instability and provides surgeons with a tool to determine which patients will benefit from stabilization. Surgical stabilization of cancer patients with SINS consistent with mechanical instability provides significant reduction in pain and improves patient mobility independent of neurologic status and stabilization technique.

Spinal Metastasis Resulting from Atypical Thymic Carcinoid: A Case Report

BACKGROUND

Thymic carcinoid with spinal metastasis is an extremely rare entity. Clinically, the tumor presents either by its endocrine manifestations or by mechanical compression of surrounding structures. However, no previously published case studies have reported neck pain and neurologic deficit in the initial presentation of an atypical thymic carcinoid.

CASE DESCRIPTION

A 56-year-old man, a nonsmoker, presented with a 12-month history of intermittent neck pain and a 1-month history of progressive numbness and weakness of the right upper limb. Cervical MRI showed multiple abnormal signals and C2 soft-tissue mass intruding into the vertebral canal. Cervical CT scan showed multiple bone lesions. The diagnosis of thymic carcinoid was obtained by preoperative lymph node biopsy. The patient underwent cervical laminectomy and occipitocervical fixation. Significant alleviation of pain and neurologic improvement were achieved. The postoperative pathological examination confirmed the diagnosis of thymic carcinoid.

CONCLUSIONS

Neck pain and neurologic deficit could be the first presentation of thymic carcinoid with spinal metastasis. Palliative surgery is an effective method to improve quality of life in patients with thymic carcinoid with spinal metastasis.

Spinal Instability Neoplastic Score (SINS): Reliability Among Spine Fellows and Resident Physicians in Orthopedic Surgery and Neurosurgery

STUDY DESIGN

Reliability analysis.

OBJECTIVES

The Spinal Instability Neoplastic Score (SINS) was developed for assessing patients with spinal neoplasia. It identifies patients who may benefit from surgical consultation or intervention. It also acts as a prognostic tool for surgical decision making. Reliability of SINS has been established for spine surgeons, radiologists, and radiation oncologists, but not yet among spine surgery trainees. The purpose of our study is to determine the reliability of SINS among spine residents and fellows, and its role as an educational tool.

METHODS

Twenty-three residents and 2 spine fellows independently scored 30 de-identified spine tumor cases on 2 occasions, at least 6 weeks apart. Intraclass correlation coefficient (ICC) measured interobserver and intraobserver agreement for total SINS scores. Fleiss's kappa and Cohen's kappa analysis evaluated interobserver and intraobserver agreement of 6 component subscores (location, pain, bone lesion quality, spinal alignment, vertebral body collapse, and posterolateral involvement of spinal elements).

RESULTS

Total SINS scores showed near perfect interobserver (0.990) and intraobserver (0.907) agreement. Fleiss's kappa statistics revealed near perfect agreement for location; substantial for pain; moderate for alignment, vertebral body collapse, and posterolateral involvement; and fair for bone quality (0.948, 0.739, 0.427, 0.550, 0.435, and 0.382). Cohen's kappa statistics revealed near perfect agreement for location and pain, substantial for alignment and vertebral body collapse, and moderate for bone quality and posterolateral involvement (0.954, 0.814, 0.610, 0.671, 0.576, and 0.561, respectively).

CONCLUSIONS

The SINS is a reliable and valuable educational tool for spine fellows and residents learning to judge spinal instability.

Treatment for Malignant Pheochromocytomas and Paragangliomas: 5 Years of Progress

PURPOSE OF REVIEW

The purpose of this manuscript is to review the progress in the field of therapeutics for malignant pheochromocytomas and sympathetic paraganglioma (MPPG) over the past 5 years.

RECENT FINDINGS

The manuscript will describe the clinical predictors of survivorship and their influence on the first TNM staging classification for pheochromocytomas and sympathetic paragangliomas, the treatment of hormonal complications, and the rationale that supports the resection of the primary tumor and metastases in patients with otherwise incurable disease. Therapeutic options for patients with bone metastasis to the spine will be presented. The manuscript will also review chemotherapy and propose a maintenance regimen with dacarbazine for patients initially treated with cyclophosphamide, vincristine, and dacarbazine. Finally, the manuscript will review preliminary results of several phase 2 clinical trials of novel radiopharmaceutical agents and tyrosine kinase inhibitors. MPPGs are very rare neuroendocrine tumors. MPPGs are usually characterized by a large tumor burden, excessive secretion of catecholamines, and decreased overall survival. Recent discoveries have enhanced our knowledge of the pathogenesis and phenotypes of MPPG. This knowledge is leading to a better understanding of the indications and limitations of the currently available localized and systemic therapies as well as the development of phase 2 clinical trials for novel medications.

Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine

Oncological management of skeletal metastases has changed dramatically in the last few decades. A significant number of patients survive for many years with their metastases.

Surgeons are more active and the technical repertoire is broader, from plates to intramedullary devices to (tumour) endoprostheses.

The philosophy of treatment should be different in the case of a trauma-related fracture and a pathological fracture. A proper algorithm for establishing a diagnosis and evaluation of prognostic factors helps in planning the surgical intervention.

The aim of palliative surgery is usually to eliminate pain and to allow the patient to regain his/her mobility as well as to improve the quality of life through minimally invasive techniques using life-long durable devices.

In a selected group of patients with an oncologically controlled primary tumour site and a solitary bone metastasis with positive prognostic factors, which meet the criteria for radical excision (approximately 10% to 15% of the cases), a promising three to five years of survival may be achieved, especially in cases of metastases from breast and kidney cancer.

Spinal metastases require meticulous evaluation because decisions on treatment mostly depend on the tumour type, segmental stability, the patient’s symptoms and general state of health.

Advanced radiotherapy combined with minimally invasive surgical techniques (minimally invasive stabilisation and separation surgery) provides durable local control with a low complication rate in a number of patients.

Cite this article: EFORT Open Rev 2017;2:372-381.

Hybrid surgery-radiosurgery therapy for metastatic epidural spinal cord compression: A prospective evaluation using patient-reported outcomes

Background

Patient-reported outcomes (PRO) represent an important measure of cancer therapy effect. For patients with metastatic epidural spinal cord compression (MESCC), hybrid therapy using separation surgery and stereotactic radiosurgery preserves neurologic function and provides tumor control. There is currently a paucity of data reporting PRO after such combined modality therapy for MESCC. Delineation of hybrid surgery-radiosurgery therapy effect on PRO validates the hybrid approach as an effective therapy resulting in meaningful symptom relief.

Patients and Methods

Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP), PROs validated in the cancer population, were prospectively collected. Patients with MESCC who underwent separation surgery followed by stereotactic radiosurgery were included. Separation surgery included a posterolateral approach without extensive cytoreductive tumor excision. A median postoperative radiosurgery dose of 2700 cGy was delivered. The change in PRO 3 months after the hybrid therapy represented the primary study outcome. Preoperative and postoperative evaluations were analyzed using the Wilcoxon signed-rank test for matched pairs.

Results

One hundred eleven patients were included. Hybrid therapy resulted in a significant reduction in the BPI items "worst" and "right now" pain (P < .0001), and in all BPI constructs (severity, interference with daily activities, and pain experience, P < .001). The MDASI-SP demonstrated reduction in spine-specific pain severity and interference with general activity (P < .001), along with decreased symptom interference (P < .001).

Conclusions

Validated PRO instruments showed that in patients with MESCC, hybrid therapy with separation surgery and radiosurgery results in a significant decrease in pain severity and symptom interference. These prospective data confirm the benefit of hybrid therapy for treatment of MESCC and should facilitate referral of patients with MESCC for surgical evaluation.

The Spinal Instability Neoplastic Score: Impact on Oncologic Decision-Making

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To address the following questions in a systematic literature review: 1. How is spinal neoplastic instability defined or classified in the literature before and after the introduction of the Spinal Instability Neoplastic Score (SINS)? 2. How has SINS affected daily clinical practice? 3. Can SINS be used as a prognostic tool?

SUMMARY OF BACKGROUND DATA

Spinal neoplastic-related instability was defined in 2010 and simultaneously SINS was introduced as a novel tool with criteria agreed upon by expert consensus to assess the degree of spinal stability.

METHODS

PubMed, Embase, and clinical trial databases were searched with the key words "spinal neoplasm," "spinal instability," "spinal instability neoplastic score," and synonyms. Studies describing spinal neoplastic-related instability were eligible for inclusion. Primary outcomes included studies describing and/or defining neoplastic-related instability, SINS, and studies using SINS as a prognostic factor.

RESULTS

The search identified 1414 articles, of which 51 met the inclusion criteria. No precise definition or validated assessment tool was used specific to spinal neoplastic-related instability prior to the introduction of SINS. Since the publication of SINS in 2010, the vast majority of the literature regarding spinal instability has used SINS to assess or describe instability. Twelve studies specifically investigated the prognostic value of SINS in patients who underwent radiotherapy or surgery.

CONCLUSION

No consensus could be determined regarding the definition, assessment, or reporting of neoplastic-related instability before introduction of SINS. Defining spinal neoplastic-related instability and the introduction of SINS have led to improved uniform reporting within the spinal neoplastic literature. Currently, the prognostic value of SINS is controversial.

LEVEL OF EVIDENCE

N/A.

Spine Instability Neoplastic Score: agreement across different medical and surgical specialties

BACKGROUND CONTEXT

Spinal instability is an acknowledged complication of spinal metastases; in spite of recent suggested criteria, it is not clearly defined in the literature.

PURPOSE

This study aimed to assess intra and interobserver agreement when using the Spine Instability Neoplastic Score (SINS) by all physicians involved in its management.

STUDY DESIGN

Independent multicenter reliability study for the recently created SINS, undertaken with a panel of medical oncologists, neurosurgeons, radiologists, orthopedic surgeons, and radiation oncologists, was carried out.

PATIENT SAMPLE

Ninety patients with biopsy-proven spinal metastases and magnetic resonance imaging, reviewed at the multidisciplinary tumor board of our institution, were included.

OUTCOME MEASURES

Intraclass correlation coefficient (ICC) was used for SINS score agreement. Fleiss kappa statistic was used to assess agreement on the location of the most affected vertebral level; agreement on the SINS category ("stable," "potentially stable," or "unstable"); and overall agreement with the classification established by tumor board.

METHODS

Clinical data and imaging were provided to 83 specialists in 44 hospitals across 14 Spanish regions. No assessment criteria were pre-established. Each clinician assessed the SINS score twice, with a minimum 6-week interval. Clinicians were blinded to assessments made by other specialists and to their own previous assessment. Subgroup analyses were performed by clinicians' specialty, experience (≤7, 8-13, ≥14 years), and hospital category (four levels according to size and complexity). This study was supported by Kovacs Foundation.

RESULTS

Intra and interobserver agreement on the location of the most affected levels was "almost perfect" (κ>0.94). Intra-observer agreement on the SINS score was "excellent" (ICC=0.77), whereas interobserver agreement was "moderate" (ICC=0.55). Intra-observer agreement in SINS category was "substantial" (k=0.61), whereas interobserver agreement was "moderate" (k=0.42). Overall agreement with the tumor board classification was "substantial" (κ=0.61). Results were similar across specialties, years of experience, and hospital category.

CONCLUSIONS

Agreement on the assessment of metastatic spine instability is moderate. The SINS can help improve communication among clinicians in oncology care.