Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007

Patient-Reported Outcomes for Spine Oncology: A Narrative Review

Spine tumors, both primary and metastatic, impose significant morbidity and mortality on patients and physicians. Patient-reported outcomes are valuable tools to assess a patient's impression of their health status and enhance communication between physicians and patients. Various spine generic patient-reported outcome tools have traditionally been used but have not been validated in the spine tumor patient population. The Spine Oncology Study Group Outcome Questionnaire, which is disease-specific for the metastatic spine patient population, has been shown to have strong validity, even across multiple languages. Patient-Reported Outcomes Measurement Information System, which has recently been developed, employs computerized adaptive testing to assess multiple health domains. It has been shown to capture information in both generic and specific questionnaires and has the potential to be used as a universal tool in the spine oncology patient population. Further long-term studies, as well as, cross-cultural adaptations, are needed to validate Patient-Reported Outcomes Measurement Information System's applicability and effectiveness.

A new era in the management of spinal metastasis

Despite the recent advances in cancer treatment, the incidence of patients with spinal metastases continues to grow along with the total number of cancer patients. Spinal metastases can significantly impair activities of daily living (ADL) and quality of life (QOL), compared with other types of bone metastases, as they are characterized with severe pain and paralysis caused by skeletal-related events. Reduced ADL can also lead to treatment limitations as certain anticancer agents and radiation therapy are not compatible treatments; thus, leading to a shorter life expectancy. Consequently, maintaining ADLs in patients with spinal metastases is paramount, and spine surgeons have an integral role to play in this regard. However, neurosurgeon, orthopedic and spinal surgeons in Japan do not have a proactive treatment approach to spinal metastases, which may prevent them from providing appropriate treatment when needed (clinical inertia). To overcome such endemic inertia, it is essential for 1) spine surgeons to understand and be more actively involved with patients with musculoskeletal disorders (cancer locomo) and cancer patients; 2) the adoption of a multidisciplinary approach (coordination and meetings not only with the attending oncologist but also with spine surgeons, radiologists, rehabilitation specialists, and other professionals) to preemptive treatment such as medication, radiotherapy, and surgical treatment; and 3) the integration of the latest findings associated with minimally invasive spinal treatments that have expanded the indications for treatment of spinal metastases and improved treatment outcomes. This heralds a new era in the management of spinal metastases.

Clinical efficacy analysis of surgical treatment for spinal metastasis under the multidisciplinary team using the NOMS decision system combined with the revised Tokuhashi scoring system: a randomized controlled study

OBJECTIVE

Despite advancements in spinal metastasis surgery techniques and the rapid development of multidisciplinary treatment models, we aimed to explore the clinical efficacy of spinal metastasis surgery performed by a combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system, compared with the Revised Tokuhashi scoring system.

METHODS

Clinical data from 102 patients with spinal metastases who underwent surgery at three affiliated hospitals of Zunyi Medical University from December 2017 to June 2022 were analysed. The patients were randomly assigned to two groups: 52 patients in the treatment group involving the combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system (i.e., the combined group), and 50 patients in the treatment group involving the Revised Tokuhashi scoring system only (i.e., the revised TSS-only group). Moreover, there were no statistically significant differences in preoperative general data or indicators between the two groups. Intraoperative and postoperative complications, average hospital stay, mortality rate, and follow-up observation indicators, including the visual analogue scale (VAS) score for pain, Eastern Cooperative Oncology Group (ECOG) performance status, Karnofsky Performance Status (KPS) score, negative psychological assessment score (using the Self-Rating Anxiety Scale, [SAS]), and neurological function recovery score (Frankel functional classification) were compared between the two groups.

RESULTS

All 102 patients successfully completed surgery and were discharged. The follow-up period ranged from 12 to 24 months, with an average of (13.2 ± 2.4) months. The patients in the combined group experienced fewer complications such as surgical wound infections 3 patients(5.77%), intraoperative massive haemorrhage 2 patients(3.85%), cerebrospinal fluid leakage 2 patients(3.85%), deep vein thrombosis 4 patients(7.69%),and neurological damage 1 patient(1.92%), than patients in the revised TSS-only group (wound infections,11 patients(22%); intraoperative massive haemorrhage, 8 patients(16%);cerebrospinal fluid leakage,5 patients(10%);deep vein thrombosis,13 patients (26%); neurological damage,2 patients (4%). Significant differences were found between the two groups in terms of surgical wound infections, intraoperative massive haemorrhage, and deep vein thrombosis (P < 0.05). The average postoperative hospital stay in the combined group (7.94 ± 0.28 days) was significantly shorter than that in the revised TSS-only group (10.33 ± 0.30 days) (P < 0.05). Long-term follow-up (1 month, 3 months, 6 months, and 1 year postoperatively) revealed better clinical outcomes in the combined group than in the revised TSS-only group in terms of VAS scores, overall KPS%, neurological function status Frankel classification, ECOG performance status, and SAS scores.(P < 0.05).

CONCLUSION

A multidisciplinary team using the NOMS combined with the Revised Tokuhashi scoring system for spinal metastasis surgery showed better clinical efficacy than the sole use of the Revised Tokuhashi scoring system. This personalized, precise, and rational treatment significantly improves patient quality of life, shortens hospital stay, reduces intraoperative and postoperative complications, and lowers mortality rates.

Postoperative survival after lumbar instrumented surgery for metastatic spinal tumors: a nationwide population-based cohort analysis

BACKGROUND

It is difficult to predict the expected survival after lumbar instrumented surgery for metastases owing to the difference among different cancer origins and the relatively short survival after surgery.

AIMS

The aim of this study is to analyze the postoperative survival period of lumbar spinal metastasis patients who underwent lumbar instrumented surgery.

METHODS

Data were collected from the Korean National Health Insurance Review and Assessment Service database. Patients who underwent lumbar spinal surgery with instrumentation between January 2011 and December 2015 for metastatic lumbar diseases were reviewed. The mean postoperative survival period of patients with metastatic lumbar cancer according to each primary cancer type was evaluated.

RESULTS

A total of 628 patients were enrolled and categorized according to primary cancer type. The overall median survival rate was 1.11±1.30 years. The three most prevalent primary cancer groups were lung, hepatobiliary, and colorectal cancers, presenting relatively short postoperative survival rates (0.93±1.25, 0.74±0.75 and 0.74±0.88 years, respectively). The best postoperative survival period was observed in breast cancer (2.23±1.83 years), while urinary tract cancer showed the shortest postoperative survival period (0.59±0.69 years).

CONCLUSION

The postoperative survival period of patients with lumbar metastatic spinal tumors according to different primary cancers after instrumented fusion was ˃1 year overall, with differences according to different primary origins. This result may provide information regarding the expected postoperative survival after instrumented surgery for lumbar spinal metastases.

Predictors for quality of life, pain and functional outcomes after surgical treatment of metastatic disease in the spine

BACKGROUND

While predictors for postoperative survival in spine tumour patients have been identified, there is limited evidence for predictors of postoperative Quality of Life (QoL), pain and functional outcome.

METHODS

One hundred and fifty-three consecutive patients, who had undergone surgery for symptomatic spinal metastases between June 2016 and April 2019, were interviewed preoperatively and during follow-ups at three, six and 12 months using the EQ-5D-3L, COMI, and ODI questionnaires. Differences in means exceeding the specific Minimal Clinically Important Difference (MCID) values were considered clinically significant.

RESULTS

Thirty-three percent of the patients were reported dead after 12 months. Only one metastasis compared to multiple metastases has 7.9 the Odds for an improved EQ-5D-3L score at three months. No neoadjuvant metastatic irradiation has 6.8 the Odds for the improvement at that time against performed radiation. A preoperative ODI score between 50.1 and 100 has 22.0 times the odds compared to the range from 0 to 50 for an improved EQ-5D-3L after three months, and 12.5 times the odds in favour of improved COMI after three months, and 13.6 times the odds for improvement of ODI at the three-month follow-up. A preoperative COMI score ranging from 5.0 to 10 has 21 times the odds of a COMI between 0 and 5 for an improved EQ-5D-3L score and 11 times the odds for an improved ODI after 12 months. Other predictors showed no statistically significant improvement.

CONCLUSION

An improvement in QoL, pain and spinal function after 12 months can be predicted by a subjective preoperative poor health condition. Impaired spinal function before surgery, a singular metastasis and no previous irradiation is predictive of improved spinal function and quality of life three months after surgery.

Outcomes in Patients with Spinal Metastases Managed with Surgical Intervention

BACKGROUND

Spinal metastases are a significant cause of morbidity in patients with advanced cancer, and management often requires surgical intervention. Although prior studies have identified factors that influence outcomes with surgery, the ability of these factors to predict outcomes remains unclear in the era of contemporary therapies, and there is a need to better identify patients who are likely to benefit from surgery.

METHODS

We performed a single-center, retrospective analysis to evaluate risk factors for poor outcomes in patients with spinal metastases treated with surgery. The primary outcome was mortality at 180 days.

RESULTS

A total of 128 patients were identified. Age ≥ 65 years at surgery (p = 0.0316), presence of extraspinal metastases (p = 0.0110), and ECOG performance scores >1 (p = 0.0397) were associated with mortality at 180 days on multivariate analysis. These factors and BMI ≤ 30 mg/kg2 (p = 0.0008) were also associated with worse overall survival.

CONCLUSIONS

Age > 65, extraspinal metastases, and performance status scores >1 are factors associated with mortality at 180 days in patients with spinal metastases treated with surgery. Patients with these factors and BMI ≤ 30 mg/kg2 had worse overall survival. Our results support multidisciplinary discussions regarding the benefits and risks associated with surgery in patients with these risk factors.

Does Low-Grade Versus High-Grade Bilsky Score Influence Local Recurrence and Overall Survival in Metastatic Spine Tumor Surgery?

BACKGROUND AND OBJECTIVES

Spinal cord compression caused by spinal tumors is measured using the epidural spinal cord compression scale, also known as the Bilsky score. Whether Bilsky score predicts short-/long-term outcomes remains unknown. The objectives were to determine the correlation of Bilsky score 0-1 vs 2-3 with regards to (1) preoperative presentation, (2) perioperative variables, and (3) long-term outcomes.

METHODS

A single-center, retrospective evaluation of a cohort of patients undergoing metastatic spine surgery was performed between 01/2010 and 01/2021. Multivariable logistic/linear/Cox regression were performed controlling for age, body mass index, race, total decompressed levels, tumor size, other organ metastases, and postoperative radiotherapy/chemotherapy.

RESULTS

Of 343 patients with extradural spinal metastasis, 92 (26.8%) were Bilsky 0-1 and 251 (73.2%) were Bilsky 2-3. Preoperatively, patients with Bilsky 2-3 lesions were older ( P = .008), presented more with sensory deficits ( P = .029), and had worse preoperative Karnofsky Performance Scale (KPS) ( P = .002). Perioperatively, Bilsky 2-3 patients had more decompressed levels ( P = .005) and transpedicular decompression ( P < .001), with similar operative time ( P = .071) and blood loss ( P = .502). Although not statistically significant, patients with Bilsky 2-3 had more intraoperative neuromonitoring changes ( P = .412). Although rates of complications ( P = .442) and neurological deficit ( P = .852) were similar between groups, patients with Bilsky 2-3 lesions had a longer length of stay ( P = .007) and were discharged home less frequently ( P < .001). No difference was found in 90-day readmissions ( P = .607) and reoperation ( P = .510) Long-term: LR ( P =.100) and time to LR (log-rank; P =0.532) were not significantly different between Bilsky 0-1 and Bilsky 2-3 lesions. However, patients with Bilsky 2-3 lesions had worse postoperative KPS ( P < .001), worse modified McCormick scale score ( P = .003), shorter overall survival (OS) (log-rank; P < .001), and worse survival at 1 year ( P = .012). Bilsky 2-3 lesions were associated with shorter OS on multivariable Cox regression (hazard ratio = 1.78, 95% CI = 1.27-2.49, P < .001), with no significant impact on time to LR (hazard ratio = 0.73, 95% CI = 0.37-1.44, P = .359).

CONCLUSION

Bilsky 2-3 lesions were associated with longer length of stay, more nonhome discharge, worse postoperative KPS/modified McCormick scale score, shorter OS, and reduced survival at 1 year. Higher-grade Bilsky score lesions appear to be at a higher risk for worse outcomes. Efforts should be made to identify metastatic spine patients before they reach the point of severe spinal cord compression..

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

STUDY DESIGN

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

OBJECTIVES

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

Unplanned Readmission After Surgery for Cervical Spine Metastases

OBJECTIVE

Patients undergoing surgery for cervical spine metastases are at risk for unplanned readmission due to comorbidities and chemotherapy/radiation. Our objectives were to: 1) report the incidence of unplanned readmission, 2) identify risk factors associated with unplanned readmission, and 3) determine the impact of an unplanned readmission on long-term outcomes.

METHODS

A single-center, retrospective, case-control study was undertaken of patients undergoing cervical spine surgery for metastatic disease between 02/2010 and 01/2021. The primary outcome of interest was unplanned readmission within 6 months. Survival analysis was performed for overall survival (OS) and local recurrence (LR).

RESULTS

A total of 61 patients underwent cervical spine surgery for metastatic disease with the following approaches: 11 (18.0%) anterior, 28 (45.9%) posterior, and 22 (36.1%) combined. Mean age was 60.9 ± 11.2 years and 38 (62.3%) were males. A total of 9/61 (14.8%) patients had an unplanned readmission, 3 for surgical reasons and 6 for medical reasons. No difference was found in demographics, preoperative Karnofsky Performance Scale (P = 0.992), motor strength (P = 0.477), or comorbidities (P = 0.213) between readmitted patients versus not. Readmitted patients had a higher rate of preoperative radiation (P = 0.009). No statistical differences were found in operative time (P = 0.893), estimated blood loss (P = 0.676), length of stay (P = 0.720), discharge disposition (P = 0.279), and operative approach (P = 0.450). Furthermore, no difference was found regarding complications (P = 0.463), postoperative Karnofsky Performance Scale (P = 0.535), and postoperative Modified McCormick Scale (P = 0.586). Lastly, unplanned readmissions were not associated with OS (log-rank; P = 0.094) or LR (log-rank; P = 0.110).

CONCLUSIONS

In patients undergoing cervical spine metastasis surgery, readmission occurred in 15% of patients, 33% for surgical reasons, and 67% for medical reasons. Preoperative radiotherapy was associated with an increased rate of unplanned readmissions, yet readmission had no association with OS or LR.

Surgical management and outcomes of spinal metastasis of malignant adrenal tumor: A retrospective study of six cases and literature review

Purpose

Spinal metastasis of malignant adrenal tumor (SMMAT) is an extremely rare and poorly understood malignant tumor originating from the adrenal gland. The objective of this study is to elucidate the clinical characteristics and discuss surgical management and outcomes of SMMAT.

Methods

Included in this study were six SMMAT patients who received surgical treatment in our center between February 2013 and May 2022. Their clinical data and outcomes were retrospectively analyzed to gain a better understanding of SMMAT. In addition, ten cases from the literature focusing on SMMAT were also reviewed.

Results

Surgery was performed successfully, and the associated symptoms were relieved significantly in all patients postoperatively. The mean follow-up duration was 26.2 (range 3-55) months. Two patients died of tumor recurrence 12 and 48 months after operation respectively. The other four patients were alive at the last follow-up.

Conclusions

The prognosis of SMMAT is usually poor. Preoperative embolization and early surgical radical resection can offer satisfactory clinical outcomes. The patient's health status, preoperative neurological function, tumor location and the resection mode are potential prognostic factors of SMMAT.

Pulmonary Function in Patients with Solitary Spinal Metastases: A Hospital-Based Cross-Sectional Study

Background

This study aimed to evaluate the pulmonary function of patients with solitary spinal metastases with the intention of providing a data-driven basis to evaluate cardiopulmonary function in patients with spinal metastases in the future.

Methods

This was a retrospective analysis of 157 patients with solitary spinal metastases in our hospital from January 2010 to December 2018. This study analyzed the influence of different stages of solitary spinal involvement on respiratory function, based on the spinal segment invaded by the metastases.

Results

The highest proportion of solitary spinal metastases occurred at the thoracic level (49.7%), with the lowest proportion at the sacral level (3.9%). The largest number of patients were in the 60-69-year age group (34.6%). There was no significant difference in pulmonary function among patients with spinal metastases at different segments (all P > 0.05). The highest vital capacity (VC), forced expiratory volume in one second (FEV₁), and forced vital capacity (FVC) were observed in patients who were overweight (all P < 0.05). There were no significant relationships between pulmonary respiratory function and body mass index (BMI) groups in male patient with spinal metastases. In female patients, the highest VC, FEV₁, FVC, and maximum voluntary ventilation were observed in patients who were overweight (all P < 0.05).

Conclusion

Thoracic vertebral metastasis was the main type of solitary spinal metastatic tumor. Spinal metastases were more common at ages 60-69 years. There was no significant difference in pulmonary function among patients with spinal metastasis at different segments. Lung function was better in patients with spinal metastases who were overweight, especially in female patients.

DEVELOPMENT OF A MATHEMATICAL MODEL OF SELECTING THE EXTENT OF A SURGICAL INTERVENTION IN SPINAL TUMOR

OBJECTIVE

The aim: To develop a mathematical model of selecting the extent of surgical intervention in the spinal tumors.

PATIENTS AND METHODS

Materials and methods: The retrospective study included 237 patients with spinal tumors who underwent the following surgeries: vertebroplasty (V); vertebroplasty and spinal fixation (F+V); posterior spinal decompression and spinal fixation (F+F); vertebrectomy and replacement of vertebra by a cage with posterior spinal fixation (F+F+K). The mathematical model is based on the modified Spine Instability Neoplastic Score (SINS). The patients were divided into two clusters. Cluster analysis was used to build a diagnostic decision tree model.

RESULTS

Results: The difference between two clusters is determined by the extent of surgical intervention, the grade of the vertebral lesion, epidural compression, and local kyphosis, and neurological signs as well. The cluster 1 included 115 patients with higher values of SINS compared to the cluster 2. All cases of vertebroplasty belonged to the cluster 2. In the cluster 1 cases of surgery of large extent: F+F; F+V; F+F+K. Analysis of the decision tree model for cluster 1 showed that a type of surgery was determined for 97 patients from 115 that relates to 84.3% of overall accuracy. The decision tree model have a high predictive accuracy for the surgery F+V and better indicators of coverage and predictive accuracy for the surgery F+F+K.

CONCLUSION

Conclusions: Our study developed a decision tree model to optimize spinal neoplasm surgery, achieving 84.3% accuracy based on significant prognosis criteria. The model considers surgical type, neurological signs, vertebra lesion grade, and stage of epidural compression, potentially improving clinical outcomes.

Postoperative Survival and Clinical Outcomes for Uterine Leiomyosarcoma Spinal Bone Metastasis: A Case Series and Systematic Literature Review

Spinal bone metastases from uterine leiomyosarcoma (LMS) are relatively uncommon and few data are present in the literature. In this study, cases of nine consecutive patients who underwent spinal surgery for metastatic uterine LMS between 2012 and 2022 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by changes in Frankel grade classification during follow-up. A systematic review of the literature was also performed to evaluate operative and postoperative factors and outcomes for patients with the same gynecological metastases to the spine. For our cases, the mean time between primary tumors to bone metastases diagnosis was 5.2 years, and the thoracic vertebrae were the most affected segment. Overall, median survival after diagnosis of metastatic spine lesions was 46 months. For the systematic review, the mean time between primary tumors to bone metastases was 4.9 years, with the lumbar spine as the most involved site of metastasis. Overall, median survival after diagnosis was 102 months. Once a spinal bone lesion from LMS is identified, surgical treatment can be beneficial and successful in alleviating symptoms. Further efforts will be crucial to identify prognostic markers as well as therapeutic targets to improve survival in these patients.

Characterization and Treatment of Spinal Tumors

The prevalence of spinal tumors is rare in comparison to brain tumors which encompass most central nervous system tumors. Tumors of the spine can be divided into primary and metastatic tumors with the latter being the most common presentation. Primary tumors are subdivided based on their location on the spinal column and in the spinal cord into intramedullary, intradural extramedullary, and primary bone tumors. Back pain is a common presentation in spine cancer patients; however, other radicular pain may be present. Magnetic resonance imaging (MRI) is the imaging modality of choice for intradural extramedullary and intramedullary tumors. Plain radiographs are used in the initial diagnosis of primary bone tumors while Computed tomography (CT) and MRI may often be necessary for further characterization. Complete surgical resection is the treatment of choice for spinal tumors and may be curative for well circumscribed lesions. However, intralesional resection along with adjuvant radiation and chemotherapy can be indicated for patients that would experience increased morbidity from damage to nearby neurological structures caused by resection with wide margins. Even with the current treatment options, the prognosis for aggressive spinal cancer remains poor. Advances in novel treatments including molecular targeting, immunotherapy and stem cell therapy provide the potential for greater control of malignant and metastatic tumors of the spine.

Clinical and Pathological Profiles of Vertebral Bone Metastases from Endometrial Cancers: Evidence from a Twenty-Year Case Series

Patients with endometrial cancer (EC) frequently have metastases to lungs, extra-pelvic nodes, and liver. Although an uncommon occurrence, cases of EC metastasis to bone, prevalently in vertebral bone, have also been reported. The objective of this study was to analyze clinical and pathological profiles of patients with EC metastatic to vertebral bone. We carried out a retrospective case series on surgically treated patients for this pathology. From 2001 to 2021, out of 775 patients with bone metastasis, 1.6% had bone metastasis from EC. The median time between the diagnosis of primary tumor and that of bone metastases was 31.5 months. Solitary bone lesion was present in 7 patients and lumbar vertebrae were the segments most affected. Pathological fractures in 46.2% of patients and spinal pain in all were present. In terms of location, 46.2% of bone metastases resided within the anterior section of the vertebra, while the remaining presented an extension within the anterior and posterior sections, with 46.1% of cases showing an extradural extra-osseous extension and paraspinous envelope. Median survival after diagnosis of bone metastasis was 11.5 months. Vertebral bone metastasis in EC is a rare phenomenon, with severe prognosis. An in-depth understanding of this topic may guide future management and treatment decisions, thus improving life expectancy and quality.

Comparative Study of Circumferential Decompression and Posterior Decompression in Palliative Surgery for Metastatic Thoracic Spinal Tumors

STUDY DESIGN

This was a case-control study.

OBJECTIVE

The present study aimed to evaluate the significance of circumferential tumor resection around the spinal cord in palliative decompression surgery for patients with metastatic spinal cord compression (MSCC) in the thoracic spine.

SUMMARY OF BACKGROUND DATA

Although the benefits of palliative surgery for MSCC are well known, the significance of circumferential tumor resection with cord compression has not yet been clarified.

MATERIALS AND METHODS

We retrospectively compared the outcomes of 45 and 34 patients with incomplete paralysis of modified Frankel grade B-D caused by MSCC with anterior cord compression (epidural spinal cord compression grade ≥2) treated at 2 different university hospitals (H1 and H2, respectively). All patients in H1 hospital underwent posterior decompression only, while all patients in H2 hospital underwent full circumferential decompression. We analyzed factors that affect the postoperative ambulatory status. evaluated by the modified Frankel classification.

RESULTS

No significant differences were observed in the epidural spinal cord compression grade, spinal instability neoplastic score, new Katagiri score, revised Tokuhashi score, or postoperative survival between patients in H1 and H2 hospitals. A multivariable logistic regression analysis identified preoperative radiotherapy [odds ratio (OR): 0.23, 95% confidential interval (CI): 0.056-0.94] as a negative risk factor and postoperative chemotherapy (OR: 5.9, 95% CI: 1.3-27.0) as a positive risk factor for an improved ambulatory status. Five and 6 patients in H1 and H2 hospitals, respectively, showed deterioration in the ambulatory status. An older age (OR: 1.1, 95% CI: 1.0-1.2) and preoperative radiotherapy (OR: 10.3, 95% CI: 1.9-55.4) were extracted as significant independent risk factors for deterioration in the ambulatory status. Circumferential decompression did not improve the clinical results of patients regardless of the degree of paralysis.

CONCLUSIONS

Preoperative radiotherapy interfered with the recovery of paralysis, and postoperative chemotherapy improved the ambulatory status. Clinical outcomes did not significantly differ between total circumferential decompression and posterior decompression, although further validation in a small number of cases is needed, such as patients with Frankel grade D.

Cross-cultural adaptation and validation of the Chinese version of the Spine Oncology Study Group Outcomes Questionnaire

Background context

Patients with spinal metastases always have a poor health-related quality of life (HRQoL) and disease- and treatment-related adverse outcomes. The Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ) has been verified and validated in English for patients with spinal metastases but not in Chinese.

Purpose

This paper aimed to complete the cross-cultural adaptation of the Chinese version of the SOSGOQ, to verify its reliability and validity, and to report on the HRQoL of Chinese patients with spinal metastases.

Study design/setting

This is a single-center, prospective, observational cross-sectional study.

Patient sample

Seventy-six patients were enrolled in this study.

Outcome measures

The SOSGOQ is made up of five HRQoL domains (physical function, neurological function, pain, mental health, social function) and post-therapy questions. The EQ-5D 3L questionnaire covers five items in mobility, self-care, usual activities, pain discomfort, and anxiety-depression, each with three answer options. The SF-36 comprises 36 items divided into eight domains.

Methods

A single-center, prospective, observational cross-sectional study involving patients with spinal metastases who underwent surgery was conducted. HRQoL was evaluated using the Chinese version of the SOSGOQ, the Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36), and the EuroQol 5-Dimension questionnaire (EQ-5D). Demographic, tumor, symptom, and treatment data, as well as Eastern Cooperative Oncology Group (ECOG) information, were collected. Internal consistency reliability, convergent validity, concurrent validity, and clinical validity were used to evaluate reliability. A Spearman’s correlation analysis was used to analyze the relationship between variables.

Results

This study enrolled 76 patients, with a mean age of 55.8 years. The kidney was the most common primary tumor site, and the thoracic spine was the most affected. The internal consistency of the overall SOSQOQ (0.907) was higher than the EQ-5D (0.819), and all items of the SOSQOQ had a high convergent validity (>0.40). The SOSGOQ was significantly correlated with the EQ-5D in respective domains (p < 0.001) and overall score (p < 0.001), whereas the SF-36 was related to the overall SOSGOQ score and most domains. Total SOSGOG was significantly sensitive to changes in ECOG (p = 0.017), prior surgery (p = 0.001), and tumor type (p = 0.026).

Conclusions

The SOSGOQ is a reliable and effective tool for evaluating HRQoL in patients with spinal metastases, with high sensitivity and specificity. Surgical treatment can significantly improve patients’ HRQoL.

Responder Analysis of Pain Relief After Surgery for the Treatment of Spinal Metastatic Tumors

BACKGROUND

Central tendency analysis studies demonstrate that surgery provides pain relief in spinal metastatic tumors. However, they preclude patient-specific probability of treatment outcome.

OBJECTIVE

To use responder analysis to study the variability of pain improvement.

METHODS

In this single-center, retrospective analysis, 174 patients were studied. Logistic regression modeling was used to associate preoperative characteristics with rating the Brief Pain Inventory (BPI) worst pain item 0 to 4. Linear regression modeling was used to associate preoperative characteristics with minimal clinically important improvement (MCI) in physical functioning defined by a 1-point decrease in the BPI Interference Construct score from preoperative baseline to 6 months postoperatively.

RESULTS

Patient-level analysis revealed that 60% of patients experienced an improvement in pain. At least half experienced a decrease in pain resulting in MCI in physical functioning. Cutpoint analysis revealed that 48% were responders. Increasing scores on the preoperative pain intensity BPI items, the MD Anderson Symptom Inventory (MDASI) Core Symptom Severity Construct, the MDASI Spine Tumor-Specific Construct, the presence of preoperative neurologic deficits, and postoperative complications were associated with lower probability of treatment success while increasing severity in all BPI pain items, and MDASI constructs were associated with increased probability of MCI in physical function. Significant mortality and loss to follow-up intrinsic to this patient population limit the strength of these data.

CONCLUSION

Although patients with milder preoperative symptoms are likely to achieve better pain relief after surgery, patients with worse preoperative symptom also benefit from surgery with adequate pain relief with an improvement in physical function.

Preoperative embolization in surgical treatment of spinal metastases originating from non-hypervascular primary tumors: a propensity score matched study using 495 patients

BACKGROUND CONTEXT

Preoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE.

PURPOSE

To assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non-hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.

STUDY DESIGN

Retrospective propensity-score matched, case-control study at 2 academic tertiary medical centers.

PATIENT SAMPLE

Patients 18 years of age or older undergoing surgery for spinal metastases originating from primary non-thyroid, non-renal cell, and non-hepatocellular tumors between January 1, 2002 and December 31, 2016 were included.

OUTCOME MEASURES

The primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality.

METHODS

In total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non-PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (<0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients.

RESULTS

Intraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4-1.2) for non-PE patients and 0.9 (IQR, 0.6-1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes.

CONCLUSIONS

Our data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non-hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.

Clinical study of preoperative skeletal muscle mass as a predictor of physical performance recovery following palliative surgery for spinal metastases

BACKGROUND

Surgical treatment of spinal metastases has been associated with high morbidity and mortality in patients with sarcopenia based on low skeletal muscle mass. We assessed physical performance using the Eastern Cooperative Oncology Group performance status scale and the Barthel Index on the 30th day after palliative surgery for spinal metastases and investigated the effectiveness of surgery according to sarcopenia assessed by skeletal muscle mass.

METHODS

We retrospectively analyzed 78 consecutive patients with thoracic and lumbar spinal metastases who underwent palliative surgery. The value of the area of the psoas major muscle at the L3 level normalized by the vertebral area was divided into first, middle, and third tertiles. Clinical variables were compared by tertile. Variables affecting the 30-day good performance status were investigated with univariate and multivariate analyses.

RESULTS

The 30-day morbidity rates were 50%, 38.5%, and 15.4% by tertile. The 30-day mortality rate was 2%; all were in the first tertile. Good preoperative performance status scores were seen in 15.4% of first and 50% of third tertile patients. Postoperatively, the performance status improved in all groups, with 30.8%, 65.4%, and 92.3% by tertile. Multivariate regression analysis revealed that a good preoperative performance status (OR: 15.50, 95% CI: 1.610-149.00, P < 0.05) and the value of the area of the psoas major muscle at the L3 level normalized by the vertebral area not in the first tertile (OR: 0.22, 95% CI: 0.06-0.82, P < 0.05) were significant predictors of a good postoperative 30-day performance status.

CONCLUSIONS

A good preoperative performance status and exclusion from the first tertile were clinical factors predicting a good postoperative 30-day performance status. In patients with large psoas muscle mass (third tertile), a good 30-day performance status can be expected after surgery, suggesting that surgery in this population should be pursued aggressively.

Bone Cement and Pedicle Screw for the Treatment of Spinal Tumors with Spinal Cord Compression and Posterior Wall Defects

OBJECTIVE

To compare the safety and efficacy of posterior internal fixation with open vertebroplasty (VP) and posterior internal fixation with open kyphoplasty (KP) in the treatment of metastatic epidural spinal cord compression (MESCC) with posterior wall destruction.

METHODS

This retrospective study, conducted between January 2016 and May 2019, equally divided 60 patients with MESCC and posterior wall destruction into two groups based on the surgical method: open vertebroplasty with pedicle screw fixation (VP group) and open kyphoplasty with pedicle screw fixation (KP group). Visual analogue scale (VAS), SF-36 scores, middle vertebral height (MVH), and posterior vertebral height (PVH) were evaluated for the two groups preoperatively, postoperatively, and 1 year after surgery. Spinal Instability Neoplastic Score, Frankel grades and complications were recorded and evaluated.

RESULTS

Five patients were excluded from the analysis, and our study cohort consisted of 55 adult patients who met the inclusion criteria. The VAS and SF-36 scores of these two groups of patients significantly improved, when compared with those before the surgery (P < 0.05). There were significant differences in total cost (8835 ± 1468 vs 9540 ± 053 USD) and cement volume (4.51 ± 0.96 ml vs 6.35 ± 1.09 ml) between two groups (P < 0.05). The MVH and PVH of these two groups of patients significantly improved, when compared with those before the surgery (P < 0.05). The MVH was significantly larger in the KP group than in the VP group postoperatively (20.15 ± 4.86 vs 17.70 ± 3.78, P < 0.05) and at the final follow-up (20.42 ± 5.59 vs 17.28 ± 3.23, P < 0.05). However, the PVH of the two groups did not significantly differ at the two postoperative follow-ups (P > 0.05). No significant differences were found in surgery time, time from surgery to discharge, blood loss and complications between both groups postoperatively (P > 0.05).

CONCLUSION

In the short term, both approaches are effective and safe in patients with MESCC and posterior wall destruction. The posterior internal fixation with open VP may be a good choice of surgical method in patients with MESCC and posterior wall defects.

Spinal metastases of bronchopulmonary cancer: Role of spinal surgery and value of prognostic scores (Modified Tokuhashi and Tomita)

INTRODUCTION

Bone metastasis is frequent in bronchopulmonary cancer. We report a series of 52 patients, and analyze indications and the efficacy of surgery.

MATERIALS AND METHODS

We retrospectively studied the records of 52 patients operated on for spinal metastases of bronchopulmonary cancer over a 6-year period from January 2009 to December 2014 in the neurosurgery department of the North Hospital of Marseille, France.

RESULTS

Mean age was 63.6 years; with a sex ratio of 3:1 (M:F). Spinal pain associated with vertebral fracture and spinal cord compression was the most frequent clinical presentation (59.6%). SINS score was ≥7 in 78.9% of cases. Karnofski Performance Status was average in 67.4% of cases. Predicted survival beyond 12 months was zero according to the modified Tokuhashi score. The surgical indication was essentially palliative. Evolution showed regression of pain in 84.6% of cases, and stabilization and improvement in motor deficit in 80.6%. Median postoperative survival was 16 months.

CONCLUSION

Our results highlight the interest of surgery for pain relief, spinal stabilization and improvement in neurological function in patients with spinal metastases of bronchopulmonary cancer, and the unreliability of predictive survival scores.

Identifying new predictive factors for survival after surgery for spinal metastases: an exploratory in-depth retrospective analysis

OBJECTIVES

In selected patients with symptomatic spinal metastasis from solid tumors, surgery improves quality of life. Since selection is key, inaccurate survival prognostication may result in poor decisions and outcomes. However, most prognostic scores suffer from suboptimal external validation and subsequent mediocre performance. This warrants the ongoing search for factors that better capture the oncological status. This exploratory study aims to identify new preoperative variables that predict survival.

METHODS

A retrospective analysis was conducted on 62 patients from a tertiary care referral center who underwent debulking and/or reconstruction surgery for spinal metastases between 2006 and 2018, and in whom detailed clinical, oncological, surgical and biochemical variables were collected. Univariate and multivariate analyses were performed for overall survival.

RESULTS

Median survival was 13.2 months. Multivariate analysis for overall survival identified that a higher number of organs with metastases, a shorter time to progression on the last line of systemic therapy before surgery (TTPbs), low serum albumin, high alkaline phosphatase, high C-reactive peptide (CRP), presence of brain metastasis and the index spinal level located in the cervical region were independently associated with shorter survival.

CONCLUSION

We confirmed previously known predictors and identified CRP and TTPbs as new variables that were strongly associated with survival. The latter variable may replace primary tumor type, as improved cancer treatments make the primary tumor type less relevant as a predictor. This study is exploratory and its findings need to be validated, preferably in large prospective multicenter studies that are aiming at improving existing models.

Local Suppression Effect of Paclitaxel-Impregnated Hydroxyapatite/Collagen on Breast Cancer Bone Metastasis in a Rat Model

Introduction

Breast cancer is one of the most frequent primary tumors that cause spinal metastases. Metastasis consequences impair both the patient's overall prognosis and quality of life. We previously developed a porous hydroxyapatite collagen composite (HAp/Col) as an osteoconductive scaffold. HAp/Col is a commercially available artificial bone that is frequently utilized in spinal fusion. Because of its high absorbance capacity, HAp/Col is regarded as a good chemical carrier.

Methods

This study investigated the effect of local administration of paclitaxel combined with HAp/Col scaffold on breast cancer metastasis. High-performance liquid chromatography was used to assess the in vitro release of paclitaxel from HAp/Col. In an in vivo rat model, the inhibitory effects of paclitaxel-impregnated scaffolds on local osteogenesis was examined, and then the local suppression effects on metastatic cancer were investigated.

Results

In vitro testing revealed that roughly 30% of the paclitaxel was released within 96 hours. Paclitaxel-impregnated HAp/Col inhibited local osteogenesis for the first 8 weeks in a rat femur. However, at 12 weeks following surgery, this negative effect appeared to have subsided. In the metastatic model, all rats in the control group reached the humane endpoint 14 days after surgery. On the other hand, the average time to the endpoint in the paclitaxel group was 26.5 days, which was substantially longer than that in the control group. Long-term survivors treated with paclitaxel had no remaining tumor cells in the femoral bone, and osteogenesis was seen surrounding the HAp/Col.

Conclusions

Paclitaxel-impregnated HAp/Col reduced local tumor development and extended the time to the target endpoint in rats with metastases from breast cancer. This study shows that local implantation of paclitaxel-impregnated HAp/Col may be a viable therapeutic option for the management of breast cancer metastases.

A Tailored Approach for Appendicular Impending and Pathologic Fractures in Solid Cancer Metastases

Simple Summary

Patients with bone metastases often suffer with complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results, a tailored approach should be defined for managing impending or pathologic fractures in each individual case. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow.

Abstract

Advances in medical and surgical treatment have played a major role in increasing the survival rates of cancer patients with metastatic bone disease. The clinical course of patients with bone metastases is often impaired by bone complications, such as bone fractures, which have a substantial negative impact on clinical outcomes. To optimize clinical results and prevent a detrimental impact on patients’ health, a tailored approach should be defined for any given patient. The optimal management of impending or pathologic fractures is unknown and relies on a multidisciplinary approach to tailor clinical decisions to each individual patient. The ability to control systemic disease, the extent, location and nature of bone metastases, and the biology of the underlying tumor, are the main factors that will define the strategy to follow. The present review covers the most recent data regarding impending and pathologic fractures in patients with bone metastases, and discusses the medical and surgical management of patients presenting with metastatic bone disease in different clinical settings.

Minimally Invasive Posterolateral Approach for Surgical Resection of Dumbbell Tumors of the Lumbar Spine

Minimally invasive spine surgery (MISS) has many advantages over traditional open surgical procedures that can be conducted for the therapy of different diseases of the spine. MISS provide many prospective advantages such as, for example, small incisions, less damage to soft tissues, early activation of patients, and a shorter postoperative hospital stay. The aim of the study was to evaluate institutional experience with Dumbbell tumors and metastatic lesions of the lumbar spine and compare it with traditional open surgical resection of this type of tumors. Fourteen patients underwent the surgery with minimally invasive posterolateral approach in experimental group, and 10 patients of the control group were operated using the traditional open surgery procedure at the Department of spinal neurosurgery and pathology of peripheral nervous system of JSC “National Center for Neurosurgery.” The intraoperative neuro monitoring system (ISIS IOM System Compact, Inomed, Germany) was used in both groups. Sensory and motor evoked potentials were intraoperatively recorded. The present study was approved by the local Ethics Committee of the National Center for Neurosurgery. Patients signed informed consent before the surgical procedure. The experimental group included 14 patients, that underwent the surgery during the period from January 2020 till March 2021. And the control group included 10 patients that was operated from January 2018 to December 2019. The results of the treatment in both groups were assessed according to the generally accepted visual analog scale (VAS) and the Oswestry scales before, on the third day, and 3 months after the surgery. In experimental group, average reduction of the pain syndrome of 3.36 points (from 3 to 0 points) was observed in patients postoperatively according to the VAS 3 days, and of 4.0 points (from 2 to 0 points) 3 months after surgical procedures. Improvement by 23.86% (36–16%) was also observed using the Oswestry Disease Index (ODI) 3 days after the surgery, and then reduced to 21.00% (16–34%) in average in 3 months. All patients were revived 3 h after transfer to the specialist department. The average stay in the hospital was 6.5 (9–4) days in both groups. In control group, average reduction of the pain syndrome of 2.60 points (from 4 to 1 points) was observed postoperatively according to the VAS 3 days after the operation, and of 3.9 points (from 2 to 0 points) 3 months after the surgery. The ODI of patients was also improved by an average of 35.40% (50–20%) 3 days after the surgical procedure, and reduced to 24.20% (16–32%) in average 3 months after the surgery.

Role of radiofrequency ablation and cement injection for pain control in patients with spinal metastasis

Background

The study aimed to investigate the effects and reliability of simultaneous vertebroplasty and radiofrequency ablation or radiofrequency ablation applied alone for pain control in patients with painful spine metastasis, and to investigate the effect of preventing tumor spread in long-term follow-up.

Methods

Patients with painful vertebrae metastasis in the Afyonkarahisar Health Sciences University, Medical Faculty, Hospital Neurosurgery Clinic between 01.01.2015 and 01.06.2020 were recruited. They were divided into groups according to the surgical procedures applied. Group 1 included 26 patients who underwent radiofrequency ablation only, and group 2 included 40 patients who underwent vertebroplasty with radiofrequency ablation. Computed tomography and magnetic resonance imaging were performed in all patients pre-operation. The patients were followed for at least 6 months. Magnetic resonance imaging was performed at the end of the 6th month in neurologically stable patients. The metastatic lesion, pain, and quality of life were evaluated with Visual Analog Scale and Oswestry Disability Survey before and after the procedure.

Results

The mean VAS score before the procedure was 8.3 ± 1.07 in the RFA group, and a statistically significant difference was observed in VAS scores at all post-procedural measurement time-points (p < 0.001). The pain scores decreased at a rate of 58.8 and 69.6% of patients showed significant improvements in the QoL in the RFA-only group. The mean VAS score was 7.44 ± 1.06 in group RFA + VP before the procedure; the difference in the mean VAS scores was statistically significant at all measurement time-points after the procedure (p < 0.001). The mean pre-treatment Oswestry Index (to assess the QoL) was 78.50% in the RFA + VP group, which improved to 14.2% after treatment.

Conclusion

Ablation + vertebroplasty performed to control palliative pain and prevent tumor spread in patients with painful vertebral metastasis is more successful than vertebroplasty performed alone.

Preoperative Embolization of Spinal Metastatic Tumor: The Use of Selective Computed Tomography Angiography for the Detection of Radiculomedullary Arteries

Introduction

Preoperative embolization for metastatic spinal cord compression (MSCC) has a risk of spinal ischemia. This study aimed to assess the efficacy and safety of preoperative embolization in patients with MSCC and evaluate the use of computed tomography (CT) angiography for the detection of the radiculomedullary arteries (RMA).

Methods

This retrospective study included 20 patients (12 men and 8 women; median age, 66 years), who underwent preoperative embolization before a decompression surgery, which corresponded to 22 embolization procedures. The detection ability of RMA was evaluated using angiography and selective CT angiography. Surgical data including intraoperative blood loss and transfusion were also evaluated.

Results

Six RMAs were identified at the levels of affected vertebrae and one level above and below in the diagnostic spinal angiography. In addition to spinal angiography, adjunctive selective CT angiography allowed visualization of another five RMAs. Overall, 11 RMAs were identified in 9 patients. Preoperative embolization was successfully achieved in all patients. As regards complications related to embolization procedure, palsy exacerbated in one patient (4.5%), which improved postoperatively. During the surgical procedure, the mean intraoperative blood loss was 353.4±254.2 mL without intraoperative transfusion in all patients.

Conclusions

The present study showed small amounts of intraoperative blood loss without any severe complications related to preoperative embolization. Selective CT angiography was a useful technique to detect RMAs and contributed to the safety of preoperative embolization.

Prognostic scores for survival as decisional support for surgery in spinal metastases: a performance assessment systematic review

PURPOSE

To review the evidence on the relative prognostic performance of the available prognostic scores for survival in spinal metastatic surgery in order to provide a recommendation for use in clinical practice.

METHODS

A systematic review of comparative external validation studies assessing the performance of prognostic scores for survival in independent cohorts was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified through Medline and Embase until May 2021. Studies were included when they compared at least four survival scoring systems in surgical or mixed cohorts across all primary tumor types. Predictive performance was assessed based on discrimination and calibration for 3-month, 1-year and overall survival, and generalizability was assessed based on the characteristics of the development cohort and external validation cohorts. Risk of bias and concern regarding applicability were assessed based on the 'Prediction model study Risk Of Bias Assessment Tool' (PROBAST).

RESULTS

Twelve studies fulfilled the inclusion criteria and covered 17 scoring systems across 5.130 patients. Several scores suffer from suboptimal development and validation. The SORG Nomogram, developed in a large surgical cohort, showed good discrimination on 3-month and 1-year survival, good calibration and was superior in direct comparison with low risk of bias and low concern regarding applicability. Machine learning algorithms are promising as they perform equally well in direct comparison. Tokuhashi, Tomita and other traditional risk scores showed suboptimal performance.

CONCLUSION

The SORG Nomogram and machine learning algorithms outline superior performance in survival prediction for surgery in spinal metastases. Further improvement by comparative validation in large multicenter, prospective cohorts can still be obtained. Given the heterogeneity of spinal metastases, superior methodology of development and validation is key in improving future machine learning systems.

Surgical Stabilization for Patients with Mechanical Back Pain Secondary to Metastatic Spinal Disease is Associated with Improved Objective Mobility Metrics: Preliminary Analysis in a Cohort of 26 Patients

OBJECTIVES

To investigate the effect of surgical stabilization for patients with metastatic spinal disease on objective mobility metrics.

METHODS

A retrospective chart review identified patients who had mechanical back pain from metastatic spinal disease and underwent spinal stabilization during 2017. Mobility metrics, the Activity Measure for Post-Acute Care (AM-PAC) inpatient mobility short form (IMSF) and the Johns Hopkins Highest Level of Mobility (JH-HLM), were reviewed.

RESULTS

A total of 26 patients were included in the analysis with median hospital stay of 8 days. Preoperative JH-HLM scores were available for 17 patients with a mean score of 5.4, increasing to mean score of 6.6 at last follow-up (P = 0.036). Preoperative AM-PAC IMSF scores were available for 14 patients with a mean score of 19.4, decreasing slightly to a mean score of 18.7 at last follow-up (P = 0.367). Last follow-up with mobility metrics occurred a median of 6.5 days postoperatively (range: 3-66 days). Multivariable analysis showed that American Spinal Injury Association and Karnofsky Performance Status scores were significantly associated with both JH-HLM and AM-PAC mobility scores at last follow-up. A higher JH-HLM or AM-PAC score was significantly associated with direct home discharge and a higher AM-PAC score was associated with shorter hospital stay.

CONCLUSIONS

Surgical stabilization for patients with mechanical back pain secondary to metastatic spinal disease might lead to an objective improvement in JH-HLM score. JH-HLM and AM-PAC scores may be correlated with length of hospital stay and discharge disposition. Future studies are encouraged to further characterize the role of these mobility metrics in the management plan of these patients.

Solitary bone plasmacytoma of the upper cervical spine: A case report

BACKGROUND

Solitary bone plasmacytoma (SBP) of the upper cervical spine is a rare diagnosis. The exact role of surgery for SBP remains unclear.

CASE SUMMARY

We present the first case of SBP of the C2. A 69-year-old Chinese woman presented with severe neck pain and limitation of rotative activity for 2 mo. She underwent anterior one-stage debridement combined with cement augmentation in the C2 to reconstruct stability of the spine. The patient did not receive postoperative radiotherapy. She now remains disease free with no neck pain or neurological deficit after follow-up of 3 years.

CONCLUSION

Anterior one-stage debridement combined with cement augmentation of the upper cervical spine may be an alternative treatment for SBP.

An Overview of Decision Making in the Management of Metastatic Spinal Tumors

INTRODUCTION

Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors.

METHODS

A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed.

DISCUSSION

Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment.

CONCLUSION

The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.

Patient outcomes and survival following surgery for spinal metastases

Context: There is no consensus on the preferred treatment for patients with spinal metastases. Little is known about the outcomes of surgery for this population. The objectives of this paper are to examine the outcomes of surgery among patients with spinal metastases suffering from cord compression (CC) or intractable pain (IP).Design: Retrospective, descriptive (level 4) case series.Setting: Rabin Medical Center, Israel.Participants: 61 patients undergoing surgery for spinal metastasis in a tertiary care hospital. Patients were divided into two groups: those with spinal CC and those with IP only.Interventions: Surgery due to CC or IP among patients with spinal metastases.Outcome measures: Frankel scale to assess neurological status, ambulatory and incontinence status, which were examined before surgery, at discharge and at last follow-up. Endpoints were death or latest follow-up visit. Survival and postoperative complications were documented.Results: There was no significant difference in Frankel score before and after surgery among patients with CC (mean score 3.5 and 3.4 respectively, P = 0.62). Complete incontinence rates significantly increased in patients with CC between preoperative and last follow-up examinations (13.6% vs. 20%, respectively, P = 0.05). Median survival of CC and IP groups was 201 and 402 days, respectively (P = 0.32). Complication rate was 41.4%.Conclusion: In our cohort, Frankel score and walking capability of patients with CC did not change postoperatively, but continence status deteriorated over time. Surgeons should advise patients on expected surgical outcomes, especially in non-ambulatory and incontinent patients.

Surgical Impacts of Metastatic Non-small Cell Lung Cancer to the Thoracic and Lumbar Spine

BACKGROUND

Surgery for spinal metastasis is rapidly increasing in frequency with procedures ranging from laminectomy to spondylectomy combined with stabilization. This study investigated the effect of various surgical procedures for spinal metastasis of non-small cell lung cancer (NSCLC).

METHODS

A single-center consecutive series of patients who underwent surgery for spinal metastasis of NSCLC were retrospectively reviewed. Patients' characteristics, radiographic parameters, operative data, clinical outcomes, and complications were analyzed. Surgical outcomes were assessed according to pain and performance status before and after surgery. Overall survival (OS) rate was estimated using the Kaplan-Meier method. Multivariate analysis was performed to detect factors independently associated with OS using a Cox proportional hazards model.

RESULTS

Twenty-one patients were treated with laminectomy, 24 with corpectomy, 13 with spondylectomy (piecemeal or total en bloc fashion), and all procedures were combined with stabilization. Back pain and performance status improved significantly after surgical treatment among the three groups. Revision surgery due to tumor progression at the index level or spinal metastasis at another level were four patients (19.0%) in the laminectomy group, six patients (25.0%) in the corpectomy group, and one patient (7.7%) in the spondylectomy group. A Charlson comorbidity index and the number of spinal metastasis negatively affected OS (hazard ratio [HR], 19.613 and 2.244). Postoperative chemotherapy, time to metastasis, spondylectomy, and corpectomy had favorable associations with OS (HR, 0.455, 0.487, 0.619, and 0.715, respectively).

CONCLUSION

Postoperative chemotherapy was the most critical factor in OS of patients with metastatic NSCLC to the spine. An extensive surgical procedure (corpectomy/spondylectomy) with stabilization also could be beneficial for limited patients with spinal metastasis of NSCLC.

Spine metastasis in patients with prostate cancer: Survival prognosis assessment

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of 30-Day Outcomes in Patients with Cervical Spine Metastasis Undergoing Corpectomy Versus Posterior Cervical Laminectomy and Fusion: A 2006-2016 ACS-NSQIP Database Study

BACKGROUND

Patients with metastatic disease to the cervical spine have historically had poor outcomes, with an average survival of 15 months. Every effort should be made to avoid complications of surgical intervention for stabilization and decompression.

METHODS

We identified patients who had undergone anterior cervical corpectomy and fusion (ACCF) or posterior cervical laminectomy and fusion (PCLF) for metastatic disease of the cervical spine using the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2016. Patients meeting the inclusion criteria were subsequently propensity matched 1:1. We compared the overall complications, intensive care unit level complications, mortality, and return to the operating room between the 2 groups.

RESULTS

After identifying the patients who met the inclusion criteria and propensity matching, a cohort of 240 patients was included, with 120 (50%) in the ACCF group and 120 (50%) in the PCLF group. The patients in the ACCF group were more likely to have experienced any complication (odds ratio, 2.1; 95% confidence interval, 1.1-4.1; P = 0.026) but not severe complications or a return to the operating room (P = 0.406 and P = 0.450, respectively).

CONCLUSION

In the present study, we found that anterior surgical approaches (ACCF) for metastatic cervical spine disease resulted in a significantly greater rate of overall complications (2.1 times more) compared with PCLF in the first 30 days. Although more studies are required to further elucidate this relationship, the general belief that the anterior approach is better tolerated by patients might not apply to patients with metastatic tumors.

CT based quantitative measures of the stability of fractured metastatically involved vertebrae treated with spine stereotactic body radiotherapy

Mechanical instability secondary to vertebral metastases can lead to pathologic vertebral compression fracture (VCF) mechanical pain, neurological compromise, and the need for surgical stabilization. Stereotactic body radiation therapy (SBRT) as a treatment for spinal metastases is effective for pain and local tumor control, it has been associated with an increased risk of VCF. This study quantified computed tomography (CT) based stability measures in metastatic vertebrae with VCF treated with spine SBRT. It was hypothesized that semi-automated quantification of VCF based on CT metrics would be related to clinical outcomes. 128 SBRT treated spinal metastases patients were identified from a prospective database. Of these, 18 vertebral segments were identified with a VCF post-SBRT. A semi-automated system for quantifying VCF was developed based on CT imaging before and after SBRT. The system identified and segmented SBRT treated vertebral bodies, calculated stability metrics at single time points and changes over time. In the vertebrae that developed a new (n = 7) or progressive (n = 11) VCF following SBRT, the median time to VCF/VCF progression was 1.74 months (range 0.53-7.79 months). Fractured thoracolumbar vertebrae that went on to be stabilized (cemented and/or instrumented), had greater fractured vertebral body volume progression over time (12%) compared to those not stabilized (0.4%, p < 0.05). Neither the spinal instability neoplastic score (SINS) or any single timepoint stability metrics in post-hoc analyses correlated with future stabilization. This pilot study presents a quantitative semi-automated method assessing fractured thoracolumbar vertebrae based on CT. Increased fractured vertebral body volume progression post-SBRT was shown to predict those patients who were subsequently stabilized, motivating study of methods that assess temporal radiological changes toward augmenting existing clinical management in the metastatic spine.

Posterior Decompression Surgery and Radiofrequency Ablation Followed by Vertebroplasty in Spinal Metastases from Lung Cancer

Background

Spinal metastases can cause metastatic epidural spinal cord compression (MESCC), which can result in neurological dysfunction and impaired quality of life. This study investigated the safety and effectiveness of posterior decompression surgery and radiofrequency ablation followed by vertebroplasty in spinal metastasis from lung cancer.

Material/Methods

From June 2008 to September 2015, a retrospective analysis was conducted in 15 patients with spinal metastasis from lung cancer. All cases suffered MESCC and underwent posterior decompression surgery to relieve the compression of spinal cord, and had radiofrequency ablation followed by vertebroplasty. All patients received postoperative multidisciplinary therapy. The operative time, blood loss, complications, pain, neurologic deficit, quality of life, and survival were assessed preoperatively and postoperatively.

Results

Patients were followed from 6 to 56 months. The mean time of operation was 154±50 minutes and the mean blood loss was 210±90 mL. In the pre-operation analysis found the mean visual analogue scale (VAS) was 7.86±0.86. In the post-operation analysis at 3 months, the mean VAS score was 3.51±1.32. The VAS improved significantly (t=7.95, P<0.01). The Frankel grade was improved 1 grade or 2 grades in 14 patients when pre-operation was compared to post-operation. Only 1 patient kept Frankel grade D after surgery. Eight patients with sphincteric dysfunction preoperatively were improved after surgery. The EORTC QLQ-C30 score was 86.13±8.51 preoperatively and 52.21±13.28 postoperatively. The quality of life was improved significantly (t=11.8, P<0.01). The median survival time was 11 months.

Conclusions

Through posterior decompression surgery and radiofrequency ablation followed by vertebroplasty, the quality of life was improved significantly. This palliative treatment was effective and safe in spinal metastasis from lung cancer.

Comparison of subtotal vertebral resection with reconstruction and percutaneous vertebroplasty for treatment of metastasis in the lumbar spine

Purpose: Tumor metastasis in the spine can cause pain and fractures, leading to deformities, and deficits in movement, sensation, and bowel/bladder function. Percutaneous vertebroplasty (PVP) and subtotal vertebral resection with reconstruction (SVR) are suitable treatments, but their relative clinical efficacy is uncertain. The purpose of this retrospective cohort study was to compare the management and clinical effect of SVR for lumbar metastatic tumor with PVP.Methods: Sixty-seven patients (mean age: 58.6 years) with metastases in the lumbar spine received SVR or PVP at our institution between 2010 and 2013. Thirty-three patients received SVR via a posterior approach, in which vertebrae were resected, with the anterior and lateral walls retained using polymethylmethacrylate (PMMA), followed by reconstruction and pedicle screw fixation. Thirty-four patients received PVP via the vertebral pedicle. Patients were followed for 3-26 months.Results: None of the patients experienced serious complications after surgery, and all patients experienced significant amelioration of pain. Twelve patients (8 in the PVP group and 4 in the SVR group) died during the follow-up, and the survival time was significantly longer in the SVR group. Two patients in the SVR group and 7 patients in the PVP groups experienced recurrence during follow-up, but the groups had no significant difference in local recurrence. Both treatments significantly reduced scores for pain on a visual analog scale (pain-VAS) and disability (Oswestry Disability Index [ODI]), and increased performance status (Karnofsky Performance Status [KPS]). Compared with the PVP group, the SVR group had better ODI score at 1 month and 3 months after surgery and a higher KPS score at 1 month after surgery. The two groups had no significant difference in pain-VAS scores during follow-up.Conclusions: SVR is a reliable treatment for lumbar metastatic tumor and provides good survival rate and satisfying follow-up results.

Prognostic Factors in the New Katagiri Scoring System After Palliative Surgery for Spinal Metastasis

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of the study was to examine survival after surgery for a metastatic spinal tumor using prognostic factors in the new Katagiri score.

SUMMARY OF BACKGROUND DATA

Surgery for spinal metastasis can improve quality of life and facilitate treatment of the primary cancer. However, choice of therapy requires identification of prognostic factors for survival, and these may change over time due to treatment advances. The new Katagiri score for the prognosis of skeletal metastasis includes classification of the primary tumor site and the effects of chemotherapy and hormonal therapy.

METHODS

The subjects were 201 patients (127 males, 74 females) who underwent surgery for spinal metastases at six facilities in the Nagoya Spine Group. Age at surgery, gender, follow-up, metastatic spine level, primary cancer, new Katagiri score (including primary site, visceral metastasis, laboratory data, performance status (PS), and chemotherapy) and survival were obtained from a prospectively maintained database.

RESULTS

Posterior decompression (n = 29) and posterior decompression and fixation with instrumentation (n = 182) were performed at a mean age of 65.9 (range, 16-85) years. Metastasis was present in the cervical (n = 19, 10%), thoracic (n = 155, 77%), and lumbar (n = 26, 13%) spine, and sacrum (n = 1, 1%). In multivariate analysis, moderate growth (HR 2.95, 95% CI, 1.27-7.89, P < 0.01) and rapid growth (HR 4.71, 95% CI, 2.78-12.31, P < 0.01) at the primary site; nodular metastasis (HR 1.53, 95% CI, 1.07-3.85, P < 0.01) and disseminated metastasis (HR 2.94, 95% CI, 1.33-5.42, P < 0.01); and critical laboratory data (HR 3.15, 95% CI, 2.06-8.36, P < 0.01), and poor PS (HR 2.83, 95% CI, 1.67-4.77, P < 0.01) were significantly associated with poor survival.

CONCLUSION

Accurate prognostic factors are important in deciding the treatment strategy in patients with spinal metastasis, and our identification of these factors may be useful for these patients.

LEVEL OF EVIDENCE

3.

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014

BACKGROUND CONTEXT

Metastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life.

PURPOSE

The purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD.

DESIGN

This was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD).

PATIENT SAMPLE

All patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study.

OUTCOME MEASURES

Mortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed.

METHODS

International Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts - those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared.

RESULTS

The number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85-3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66-3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18-1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41-1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68-2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20-2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27-2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53-0.96, p=.026).

CONCLUSIONS

The number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.

How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database

BACKGROUND

The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database.

METHODS

The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed.

RESULTS

A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%.

CONCLUSION

We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.

Impact of decompressive laminectomy on the functional outcome of patients with metastatic spinal cord compression and neurological impairment

Metastatic spinal cord compression (MSCC) is a frequent phenomenon in advanced tumor diseases with often severe neurological impairments. Affected patients are often treated by decompressive laminectomy. To assess the impact of this procedure on Karnofsky Performance Index (KPI) and Frankel Grade (FG) at discharge, a single center retrospective cohort study of neurologically impaired MSCC-patients treated with decompressive laminectomy between 2004 and 2014 was performed. 101 patients (27 female/74 male; age 66.1 ± 11.5 years) were identified. Prostate was the most common primary tumor site (40%) and progressive disease was present in 74%. At admission, 80% of patients were non-ambulatory (FG A–C). Imaging revealed prevalently thoracic MSCC (78%). Emergency surgery (< 24 h) was performed in 71% and rates of complications and revision surgery were 6% and 4%, respectively. At discharge, FG had improved in 61% of cases, and 51% of patients had regained ambulation. Univariate predictors for not regaining the ability to walk were bowl dysfunction (p = 0.0015), KPI < 50% (p = 0.048) and FG < C (p = 0.001) prior to surgery. In conclusion, decompressive laminectomy showed beneficial effects on the functional outcome at discharge. A good neurological status prior to surgery was key predictor for a good functional outcome.

Spinal Metastasis Surgery: A Proposal for a Predictive Model of Morbidity and Mortality

Objective  To develop a predictive model of early postoperative morbidity and mortality with the purpose of assisting in the selection of the candidates for spinal metastasis surgery.

Methods  A retrospective analysis of consecutive patients operated for metastatic spinal disease. The possible prognostic preoperative characteristics were gender, age, comorbidities, tumor growth rate, and leukocyte and lymphocyte count in the peripheral blood. The postoperative outcomes were 30-day mortality, 90-day mortality and presence of complications. A predictive model was developed based on factors independently associated with these three outcomes. The final model was then tested for the tendency to predict adverse events, discrimination capacity and calibration.

Results  A total of 205 patients were surgically treated between 2002 and 2015. The rates of the 30-day mortality, 90-day mortality and presence of complications were of 17%, 42% and 31% respectively. The factors independently associated with these three outcomes, which constituted the predictive model, were presence of comorbidities, no slow-growing primary tumor, and lymphocyte count below 1,000 cells/µL. Exposure to none, one, two or three factors was the criterion for the definition of the following categories of the predictive model: low, moderate, high and extreme risk respectively. Comparing the risk categories, there was a progressive increase in the occurrence of outcomes, following a linear trend. The discrimination capacity was of 72%, 73% and 70% for 30-day mortality, 90-day mortality and complications respectively. No lack of calibration occurred.

Conclusion  The predictive model estimates morbidity and mortality after spinal metastasis surgery and hierarchizes risks as low, moderate, high and extreme.

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

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

Outcomes of surgical treatments of spinal metastases: a prospective study

BACKGROUND

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.

OBJECTIVE

To analyse the outcomes of surgical treatments of spinal metastases.

METHODS

Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.

RESULTS

A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.

CONCLUSION

Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.