Surgical strategy for spinal metastases

Medium to Long-Term Clinical Outcomes of Spinal Metastasectomy

The prolonged survival of metastatic cancer patients highlights the importance of the local control of spinal metastases, which reduce patient performance status. This retrospective study examined the medium to long-term outcomes of spinal metastasectomy by evaluating 124 patients who underwent metastasectomy for isolated spinal metastases (2006-2018) with a postoperative follow-up for a minimum of 3 years. The findings present information on patient demographics (i.e., performance status, location of non-spinal metastases, and history of systemic therapy) and postoperative outcomes, including perioperative complications, disease progression of non-operated metastases, and additional excisional surgeries. Additionally, postoperative survival, local tumor control in the operated spine, and maintenance of spinal reconstruction without instrumentation failure were determined using Kaplan-Meier analyses. The primary malignancy was kidney and thyroid cancer in 51 and 14 patients, respectively, low-grade sarcoma and lung cancer in 13 patients, breast cancer in 12 patients, and other malignancies in 21 patients. The 3-year and 5-year survival rates were 70% and 60%, respectively. We found that patients with thyroid cancer had the best survival results, with local tumor recurrence and instrumentation failure at 10% and 22%, respectively. These findings suggest that for certain patients with isolated and removable spine metastases, metastasectomy can improve function and survival.

Spinal cord compression of neoplastic origin: surgical experience using a common clinical language

PURPOSE

To assess the value of a common clinical language in a multidisciplinary tumour board for spinal metastasis, using both the Rades score and the Spinal Instability Neoplastic Score (SINS) for multidisciplinary decision-making.

METHODS

Retrospective study of 60 consecutive patients treated surgically for MSCC. The indication for surgery was done in a multidisciplinary board, basically according to SINS and RADES scores. Three prognostic groups were defined according to the Rades score: poor (Rades 1: 20-30 points), intermediate (Rades 2: 31-35), and good (Rades 3: 36-45).

RESULTS

The 2-year overall survival (OS) rate was 50%, with median survival of 19 months. By Rades prognostic group (1, 2, 3), median OS was 6 months, 15 months, and not reached, respectively. OS rates at 6 months (Rades 1, 2, 3) were 51, 69, and 74.1%, respectively. Within the Rades 1 group, 6-month survival in patients with new-onset cancer was 68 vs. 40% in those with a known primary. The overall complication rate ≥ grade 3 was 23.3% (n = 14). In patients who underwent urgent surgery (< 48 h), the complication rate was 45.5% (5/11) versus 18.3% (9/49) in the planned surgeries.

CONCLUSIONS

Our findings supports the utility of using a common language in multidisciplinary tumour board for spinal metastasis. The 2-year OS rate in this series was 50%, which is the highest OS reported to date in this population. In the poor prognosis subgroup (Rades 1), OS at 6 months was higher in patients with new-onset cancer versus those with a known primary (68 vs. 40%). These findings suggest that surgery should be the first treatment option in patients with MSCC as first symptom of cancer although a predicted poor prognosis.

Comparison of open versus minimally invasive surgery in the treatment of thoracolumbar metastases

INTRODUCTION

Minimally invasive surgery (MIS) techniques have been developed for the surgical treatment of thoracolumbar spinal metastases to reduce the morbidity associated with the operation. The purpose of our study was to compare the mean length of stay, change in pain levels, neurological symptoms, complications and survival after open versus MIS surgery.

MATERIAL AND METHODS

This is a single-center retrospective study based on a register of patients treated for vertebral metastases between January 2014 and October 2016. The collection included demographic data, cancer-related data, clinical data, the characteristics of the surgery, the length of stay, assessment of pain and the occurrence of death. These data were compared between open and MIS surgery groups.

RESULTS

Out of 59 patients, 35 were treated with open surgery and 24 were treated with MIS surgery. The two groups were comparable in terms of age, gender and body mass index. Breast, kidney, prostate and lung cancers were the most frequent primary tumors. Prognostic and instability scores were comparable. Short- and medium-term pain assessment showed comparable results. Median survival was 208 days in the open surgery group and 224days in the MIS group (p=0.5299).

CONCLUSION

MIS techniques aim to limit the surgical approach and allow a faster introduction of adjuvant treatments than after open surgery. Our study did not find any differences between open and MIS surgery in terms of pain, neurological evolution or survival time in patients treated for thoracolumbar spinal metastases.

LEVEL OF EVIDENCE

IV; retrospective study.

Cost Analysis With Use of Expandable Cage or Cement in Single level Thoracic Vertebrectomy in Metastasis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Patient with metastatic cancer frequently require spinal operations for neural decompression and stabilization, most commonly thoracic vertebrectomy with reconstruction. Objective of the study was to assess economic aspects associated with use of cement versus expandable cage in patients with single level thoracic metastatic disease. We also looked at the differences in the clinical, radiological, complications and survival differences to assess non-inferiority of PMMA over cages.

METHODS

The electronic medical records of patients undergoing single level thoracic vertebrectomy and reconstruction were reviewed. Two groups were made: PMMA and EC. Totals surgical cost, implant costs was analyzed. We also looked at the clinical/ radiological outcome, complication and survival analysis.

RESULTS

96 patients were identified including 70 one-level resections. For 1-level surgeries, Implant costs for use of cement-$75 compared to $9000 for cages. Overall surgical cost was significantly less for PMMA compared to use of EC. No difference was seen in clinical outcome or complication was seen. We noticed significantly better kyphosis correction in the PMMA group.

CONCLUSIONS

Polymethylmethacrylate cement offers significant cost advantage for reconstruction after thoracic vertebrectomy. It also allows for better kyphosis correction and comparable clinical outcomes and non-inferior to cages.

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.

ESTRO ACROP guidelines for external beam radiotherapy of patients with uncomplicated bone metastases

After liver and lungs, bone is the third most common metastatic site (Nystrom et al., 1977). Almost all malignancies can metastasize to the skeleton but 80% of bone metastases originate from breast, prostate, lung, kidney and thyroid cancer (Mundy, 2002). Introduction of effective systemic treatment in many cancers has prolonged patients' survival, including those with bone metastases. Bone metastases may significantly reduce quality of life due to related symptoms and possible complications, such as pain and neurologic compromise. The most serious complications of bone metastases are skeletal-related events (SRE), defined as pathologic fracture, spinal cord compression, pain, or other symptoms requiring an urgent intervention such as surgery or radiotherapy. In turn, growing access to modern diagnostic tools allows early detection of asymptomatic bone metastases that could be successfully managed with local treatment avoiding development of SRE. The treatment for bone metastases should focus on relieving existing symptoms and preventing new ones. Radiotherapy is the standard of care for patients with symptomatic bone metastases, providing durable pain relief with minimal toxicity and reasonable cost-effectiveness. Historically, the dose was prescribed in one to five fractions and delivered using simple planning techniques. While 3D-conformal radiotherapy is still widely used for treating bone metastases, introduction of highlyconformal radiotherapy techniques such as stereotactic body radiotherapy (SBRT) have opened new therapeutic possibilities that should be considered in selected patients with bone metastases.

Georg schmorl prize of the German spine society (DWG) 2021: Spinal Instability Spondylodiscitis Score (SISS)-a novel classification system for spinal instability in spontaneous spondylodiscitis

PURPOSE

Even though spinal infections are associated with high mortality and morbidity, their therapy remains challenging due to a lack of established classification systems and widely accepted guidelines for surgical treatment. This study's aim therefore was to propose a comprehensive classification system for spinal instability based on the Spinal Instability Neoplastic Score (SINS) aiding spine surgeons in choosing optimal treatment for spontaneous spondylodiscitis.

METHODS

Patients who were treated for spontaneous spondylodiscitis and received computed tomography (CT) imaging were included retrospectively. The Spinal Instability Spondylodiscitis Score (SISS) was developed by expert consensus. SINS and SISS were scored in CT-images by four readers. Intraclass correlation coefficients (ICCs) and Fleiss' Kappa were calculated to determine interrater reliabilities. Predictive validity was analyzed by cross-tabulation analysis.

RESULTS

A total of 127 patients were included, 94 (74.0%) of which were treated surgically. Mean SINS was 8.3 ± 3.2, mean SISS 8.1 ± 2.4. ICCs were 0.961 (95%-CI: 0.949-0.971) for total SINS and 0.960 (95%-CI: 0.946-0.970) for total SISS. SINS yielded false positive and negative rates of 12.5% and 67.6%, SISS of 15.2% and 40.0%, respectively.

CONCLUSION

We show high reliability and validity of the newly developed SISS in detecting unstable spinal lesions in spontaneous spondylodiscitis. Therefore, we recommend its use in evaluating treatment choices based on spinal biomechanics. It is, however, important to note that stability is merely one of multiple components in making surgical treatment decisions.

Spinal metastasis: narrative reviews of the current evidence and treatment modalities

The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.

The Palliative Care in the Metastatic Spinal Tumors. A Systematic Review on the Radiotherapy and Surgical Perspective

Spine represents the most common site for metastatic disease involvement. Due to the close relationship between the spinal cord and critical structures, therapeutical management of metastatic spinal cord disease remains challenging. Spinal localization can lead to neurological sequelae, which can significantly affect the quality of life in patients with a limited life expectancy. The authors conducted a systematic literature review according to PRISMA guidelines in order to determine the impact of the most updated palliative care on spinal metastases. The initial literature search retrieved 2526 articles, manually screened based on detailed exclusion criteria. Finally, 65 studies met the inclusion criteria and were finally included in the systematic review. In the wide scenario of palliative care, nowadays, recent medical or surgical treatments represent valuable options for ameliorating pain and improving patients QoL in such this condition.

Translational Strategies to Target Metastatic Bone Disease

Metastatic bone disease is a common and devastating complication to cancer, confounding treatments and recovery efforts and presenting a significant barrier to de-escalating the adverse outcomes associated with disease progression. Despite significant advances in the field, bone metastases remain presently incurable and contribute heavily to cancer-associated morbidity and mortality. Mechanisms associated with metastatic bone disease perpetuation and paralleled disruption of bone remodeling are highlighted to convey how they provide the foundation for therapeutic targets to stem disease escalation. The focus of this review aims to describe the preclinical modeling and diagnostic evaluation of metastatic bone disease as well as discuss the range of therapeutic modalities used clinically and how they may impact skeletal tissue.

Cement leakage in percutaneous vertebroplasty for spinal metastases: a retrospective study of risk factors and clinical outcomes

Objective

The objective of this research was to investigate the risk factors of cement leakage in patients with metastatic spine tumors following percutaneous vertebroplasty (PVP).

Methods

Sixty-four patients with 113 vertebrae were retrospectively reviewed. Various clinical indexes, including age, sex, body mass index (BMI), smoking history, drinking history, chemotherapy history, radiotherapy history, primary cancer, location, other metastases, collapse, posterior wall defects, the laterality of injection, and the injected cement volume were analyzed as potential risk factors. Multivariate analyses were conducted to identify the independent risk factors.

Results

The cement leakage was found 64 in 113 treated vertebrae (56.63%), in which the incidence of each type was shown as below: spinal canal leakage 18 (15.93%), intravascular leakage around the vertebrae 11 (9.73%), and intradiscal and paravertebral leakage 35 (30.97%). Tomita classification (P = 0.019) and posterior wall destruction (P = 0.001) were considered strong risk factors for predicting cement leakage in general. The multivariate logistic analysis showed that defects of the posterior wall (P = 0.001) and injected volume (P = 0.038) were independently related to the presence of spinal canal leakage. The postoperative visual analog scale (VAS) and activities of daily living (ADL) scores showed significant differences compared with the pre-operative parameters (P < 0.05). No significant differences were found in every follow-up time between the leakage group and the non-leakage group for pain management and improvement of activities in daily life.

Conclusion

In our study, Tomita classification and the destruction of the posterior wall were independent risk factors for leakage in general. The defects of the posterior wall and injected volume were independently related to the presence of spinal canal leakage. The PVP procedure can be an effective way to manage the pain.

Vessel-Plasty Using Bone-Filling Mesh Container for Treatment of Malignant Severe Compression Fractures in Cervical Vertebrae

Objective

To evaluate the feasibility, safety, and efficacy of vessel-plasty using bone-filling mesh container (BFMC) for malignant severe compression fractures of cervical vertebra.

Methods

This study prospectively recruited fifteen consecutive patients (eight men, seven women; mean age, 57.4 years) with severe malignant compression fractures of cervical vertebrae for vessel-plasty. Procedure duration, incidence of cement leakage and other complications, pain relief and improvement of neck function were analyzed. Pain was assessed using a visual analog scale (VAS) and function by the neck disability index (NDI), with scores recorded before the procedure and at 3 days and 1, 3, 6 and 12 months after the procedure.

Results

A total of 16 vertebrae were treated. All vertebrae had destruction of bone in more than one place as well as broken bone walls. Mean procedure duration was 42.9±13.6 minutes. Bone cement leakage occurred in two vertebrae without any symptoms. No procedure-related complications occurred. Mean VAS and NDI declined from 7.1 ± 1.4 and 63.6 ± 16.3, respectively, before the procedure to 3.5 ± 1.1 and 37.4 ± 11.0, respectively, at three days after the procedure (P < 0.01). CT images at three months after the procedure confirmed that there were no cases of refractures at the treated or adjacent levels, recurrence of vertebral collapse and mobilization of bone cement block.

Conclusion

Vessel-plasty using BFMC appears to be effective and safe for malignant severe compression fractures in cervical vertebrae. It is effective in stabilizing vertebral body, relieving pain.

Body composition predictors of mortality on computed tomography in patients with spinal metastases undergoing surgical treatment

BACKGROUND CONTEXT

Although survival of patients with spinal metastases has improved over the last decades due to advances in multi-modal therapy, there are currently no reliable predictors of mortality. Body composition measurements obtained using computed tomography (CT) have been recently proposed as biomarkers for survival in patients with and without cancer. Patients with cancer routinely undergo CT for staging or surveillance of therapy. Body composition assessed using opportunistic CTs might be used to determine survival in patients with spinal metastases.

PURPOSE

The purpose of this study was to determine the value of body composition measures obtained on opportunistic abdomen CTs to predict 90-day and 1-year mortality in patients with spinal metastases undergoing surgery. We hypothesized that low muscle and abdominal fat mass were positive predictors of mortality.

STUDY DESIGN

Retrospective study at a single tertiary care center in the United States.

PATIENT SAMPLE

This retrospective study included 196 patients between 2001 and 2016 that were 18 years of age or older, underwent surgical treatment for spinal metastases, and had a preoperative CT of the abdomen within three months prior to surgery.

OUTCOME MEASURES

Ninety-day and 1-year mortality by any cause.

METHODS

Quantification of cross-sectional areas (CSA) and CT attenuation of abdominal subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and paraspinous and abdominal skeletal muscle were performed on CT images at the level of L4 using an in-house automated algorithm. Sarcopenia was determined by total muscle CSA (cm²) divided by height squared (m²) with cutoff values of <52.4 cm²/m² for men and <38.5 cm²/m² for women. Bivariate and multivariate Cox proportional-hazard analyses were used to determine the associations between body compositions and 90-day and 1-year mortality.

RESULTS

The median age was 62 years (interquartile range=53-70). The mortality rate for 90-day was 24% and 1-year 54%. The presence of sarcopenia was associated with an increased 1-year mortality rate of 66% compared with a 1-year mortality rate of 41% in patients without sarcopenia (hazard ratio, 1.68; 95% confidence interval, 1.08-2.61; p=.02) after adjusting for various clinical factors including primary tumor type, ECOG performance status, additional metastases, neurology status, and systemic therapy. Additional analysis showed an association between sarcopenia and increased 1-year mortality when controlling for the prognostic modified Bauer score (HR, 1.58; 95%CI, 1.04-2.40; p=.03). Abdominal fat CSAs or muscle attenuation were not independently associated with mortality.

CONCLUSIONS

The presence of sarcopenia is associated with an increased risk of 1-year mortality for patients surgically treated for spinal metastases. Sarcopenia retained an independent association with mortality when controlling for the prognostic modified Bauer score. This implies that body composition measurements such as sarcopenia could serve as novel biomarkers for prediction of mortality and may supplement other existing prognostic tools to improve shared decision making for patients with spinal metastases that are contemplating surgical treatment.

The performance of frailty in predictive modeling of short-term outcomes in the surgical management of metastatic tumors to the spine

BACKGROUND CONTEXT

The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden.

PURPOSE

The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease.

STUDY DESIGN/SETTING

Retrospective analysis of a nationwide database to include patients undergoing spinal fusion for metastatic spine disease.

PATIENT SAMPLE

A total of 1,974 frail patients who received spinal fusion with spinal metastasis, and 1,975 propensity score matched non-frail patients.

OUTCOME MEASURES

Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs.

METHODS

A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub-group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI).

RESULTS

7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n=1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC=0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups.

CONCLUSIONS

A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty.

Mechanical Failure After Total En Bloc Spondylectomy and Salvage Surgery

Objective

Total en bloc spondylectomy (TES) is a curative surgical method for spinal tumors. After resecting the 3 spinal columns, reconstruction is of paramount importance. We present cases of mechanical failure and suggest strategies for salvage surgery.

Methods

The medical records of 19 patients who underwent TES (9 for primary tumors and 10 for metastatic tumors) were retrospectively reviewed. Previously reported surgical techniques were used, and the surgical extent was 1 level in 16 patients and 2 levels in 3 patients. A titanium-based mesh-type interbody spacer filled with autologous and cadaveric bone was used for anterior support, and a pedicle screw/rod system was used for posterior support. Radiotherapy was performed in 11 patients (pre-TES, 5; post-TES, 6). They were followed up for 59 ± 38 months (range, 11–133 months).

Results

During follow-up, 8 of 9 primary tumor patients (89%) and 5 of 10 metastatic tumor patients (50%) survived (mean survival time, 124 ± 8 months vs. 51 ± 13 months; p=0.11). Mechanical failure occurred in 3 patients (33%) with primary tumors and 2 patients (20%) with metastatic tumors (p=0.63). The mechanical failure-free time was 94.4 ± 14 months (primary tumors, 95 ± 18 months; metastatic tumors, 68 ± 16 months; p=0.90). Revision surgery was performed in 4 of 5 patients, and bilateral broken rods were replaced with dual cobalt-chromium alloy rods. Repeated rod fractures occurred in 1 of 4 patients 2 years later, and the third operation (with multiple cobalt-chromium alloy rods) was successful for over 6 years.

Conclusion

Considering the difficulty of reoperation and patients’ suffering, preemptive use of a multiple-rod system may be advisable.

Unilateral Biportal Endoscopic Tumor Removal and Percutaneous Stabilization for Extradural Tumors: Technical Case Report and Literature Review

Background:

Extradural spinal tumors arise from soft or bony tissues in the spine and account for majority of spinal tumors. Interest in the unilateral biportal endoscopic (UBE) technique is rising, because it can easily decompress the bony spinal canal and accommodate all open surgical instruments under endoscopic guidance. However, reports of this technique have been limited to certain diseases. This study first demonstrates the UBE technique for extradural tumor biopsy and removal, and percutaneous stabilization in a 72-year-old female patient with dramatic symptom improvement.

Methods

We used the UBE technique for decompression and the percutaneous screw fixation technique for stabilization in a patient with an extradural mass compressing the thecal sac and destroying the posterior element. Under endoscopic guidance, a unilateral approach was used, and decompression and flavectomy were performed bilaterally. After decompression, tumor removal and biopsy were performed using various forceps and biopsy needles. After confirming sufficient spinal canal decompression, the screw was placed percutaneously. We evaluated the technical process of the procedure, the patient's pre- and postoperative pain (using the visual analog scale), and operative radiology and pathologic results.

Results

Postoperative pain and disability improved clinically, and spinal alignment stabilized radiologically. As the pathology findings confirmed an aneurysmal bone cyst, the treatment was completed without adjuvant therapy.

Conclusions

We treated an unstable spine due to an extradural tumor with the UBE and percutaneous screw techniques.

Decreased psoas muscle area is a prognosticator for 90-day and 1-year survival in patients undergoing surgical treatment for spinal metastasis

BACKGROUND AND AIMS

Survival estimation for patients with spinal metastasis is crucial to treatment decisions. Psoas muscle area (PMA), a surrogate for total muscle mass, has been proposed as a useful survival prognosticator. However, few studies have validated the predictive value of decreased PMA in an Asian cohort or its predictive value after controlling for existing preoperative scoring systems (PSSs). In this study, we aim to answer: (1) Is PMA associated with survival in Han Chinese patients with spinal metastasis? (2) Is PMA a good prognosticator according to concordance index (c-index) and decision curve analysis (DCA) after controlling for six existing and commonly used PSSs?

METHODS

This study included 180 adult (≥18 years old) Taiwanese patients with a mean age of 58.3 years (range: 22-85) undergoing surgical treatment for spinal metastasis. A patient's PMA was classified into decreased, medium, and large if it fell into the lower (0-33%), middle (33-67%), and upper (67-100%) 1/3 in the study cohort, respectively. We used logistic and cox proportional-hazard regressions to assess whether PMA was associated with 90-day, 1-year, and overall survival. The model performance before and after addition of PMA to six commonly used PSSs, including Tomita score, original Tokuhashi score, revised Tokuhashi score, modified Bauer score, New England Spinal Metastasis Score, and Skeletal Oncology Research Group machine learning algorithms (SORG-MLAs), was compared by c-index and DCA to determine if PMA was a useful survival prognosticator.

RESULTS

Patients with a larger PMA is associated with better 90-day, but not 1-year, survival. The model performance of 90-day survival prediction improved after PMA was incorporated into all PSSs except SORG-MLAs. PMA barely improved the discriminatory ability (c-index, 0.74; 95% confidence interval [CI], 0.67-0.82 vs. c-index, 0.74; 95% CI, 0.66-0.81) and provided little gain of clinical net benefit on DCA for SORG-MLAs' 90-day survival prediction.

CONCLUSIONS

PMA is a prognosticator for 90-day survival and improves the discriminatory ability of earlier-proposed PSSs in our Asian cohort. However, incorporating PMA into more modern PSSs such as SORG-MLAs did not significantly improve its prediction performance.

Radiomics biopsy signature for predicting survival in patients with spinal bone metastases (SBMs)

•

Prediction of survival is crucial for guiding patient-tailored treatment.

•

Radiomics can be described as the next era of possibilities in precision medicine.

•

Radiomics model had an inferior performance with no added predictive power to the clinical predictive model.

Study design

Retrospective analysis of a registered cohort of patients treated and irradiated for metastases in the spinal column in a single institute.

Objective

This is the first study to develop and internally validate radiomics features for predicting six-month survival probability for patients with spinal bone metastases (SBM).

Background data

Extracted radiomics features from routine clinical CT images can be used to identify textural and intensity-based features unperceivable to human observers and associate them with a patient survival probability or disease progression.

Methods

A study was conducted on 250 patients treated for metastases in the spinal column irradiated for the first time between 2014 and 2016, at the MAASTRO clinic in Maastricht, the Netherlands. The first 150 available patients were used to develop the model and the subsequent 100 patient were considered as a test set for the model. A bootstrap (B = 400) stepwise model selection, which combines both the forward and backward variable elimination procedure, was used to select the most useful predictive features from the training data based on the Akaike information criterion (AIC). The stepwise selection procedure was applied to the 400 bootstrap samples, and the results were plotted as a histogram to visualize how often each variable was selected. Only variables selected more than 90 % of the time over the bootstrap runs were used to build the final model.

A prognostic index (PI) called radiomics score (radscore) and clinical score (clinscore) was calculated for each patient. The prognostic index was not scaled, the original values were used which can be extracted from the model directly or calculated as a linear combination of the variables in the model multiplied by the respective beta value for each patient.

Results

The clinical model had a good discrimination power. The radiomics model, on the other hand, had an inferior performance with no added predictive power to the clinical model. The internal imaging characteristics do not seem to have a value in the prediction of survival. However, the Shape features were excluded from further analyses in our study since all biopsies had a standard shape hence no variability.

Postoperative outcomes of subaxial cervical spine metastasis: Comparison among the anterior, posterior, and combined approaches

•

The combined therapy produced better clinical results and a longer survival.

•

Perioperative complications are significantly higher with combined approach.

•

Anterior and posterior approach have the same neurological improvement rate.

Background

The incidence of subaxial spinal metastases increases due to longer life expectancy resulting from successful modern cancer treatments. The three most utilized approaches for surgical treatment include the anterior, posterior, and combined approaches. However, despite increasing surgical volume, data on the postoperative complication profiles of different operative approaches for this patient population is scarce.

Methods

The institutional databases of two large referral centers in Thailand were retrospectively reviewed. Patients with subaxial cervical spine metastasis who underwent cervical surgery during 2005 to 2015 were identified and enrolled. Clinical presentations, baseline characteristics, operative approach, perioperative complications, and postoperative outcomes, including pain, neurological recovery, and survival, were compared among the three surgical approaches.

Results

The 70 patients (44 with anterior approach, 14 with posterior approach, 12 with combined approach) were enrolled. There were no statistically significant differences in preoperative characteristics, including Charlson Comorbidity Index (CCI), Tomita score, and Revised Tokuhashi score, among the three groups. There were no significant differences among groups for medical complications, surgical complications, neurological recovery, verbal pain score improvement, survival time, or ambulatory status improvement. However, the combined approach did show a significantly higher rate of overall perioperative complications (p = 0.01), intraoperative blood loss (p < 0.001), and operative time (p < 0.001) compared to the other two approaches.

Conclusions

Patients in the combined approach group had the highest rates of perioperative complications. However, although the differences were not statistically significant, patients in the combined group tended to have better clinical outcomes after follow-up and the longest survival time.

The role of surgery in the treatment of metastatic bone tumor

Surgery for bone metastasis has two primary goals-palliative care to relieve pain, instability and paralysis, and tumor resection for curing the disease. Oncologically en bloc resection, followed by a reconstruction of the bone defect is the treatment of choice in single bone metastasis from renal cell carcinoma or thyroid cancer. Bone metastases may occur in the extremities, pelvis, or spine, and different resection and reconstruction methods depend on the regional anatomy. For instance, multiple options are available for reconstruction of the pelvis, especially for the acetabulum, including anatomical reconstruction using custom-made implants or recycled autologous bone grafting when a long-term prognosis is expected. Recently, for the spine, total en bloc spondylectomy is extensively performed despite the initial limitations of surgical invasiveness, such as blood loss. Principally, palliative surgery aims to maintain lasting bony stability with minimal surgical invasiveness. Intramedullary nails and plate fixation are frequently used in the extremities but the postoperative failure rate is relatively high. Therefore, surgeons should consider the use of long intramedullary nails and long-type stems for endoprosthesis reconstruction along with cement fixation to reduce the failure rate. Although short-term complications, such as dislocation, have been observed with endoprosthesis reconstruction, it is stable in the long-term follow-up. Percutaneous bone cement injection into the spine and pelvis is also effective and less invasive.

Postoperative outcomes of minimally invasive pedicle screw fixation for treatment of unstable pathologic neoplastic fractures

STUDY DESIGN

Retrospective Case Series.

OBJECTIVES

Minimally invasive techniques have emerged as a useful tool in the treatment of neoplastic spine pathology due to decrease in surgical morbidity and earlier adjuvant treatment. The objective of this study was to analyze outcomes and complications in a cohort of unstable, symptomatic pathologic fractures treated with percutaneous pedicle screw fixation (PPSF).

METHODS

A retrospective review was performed on consecutive patients with spinal stabilization for unstable pathologic neoplastic fractures between 2007 and 2017. Patients who underwent PPSF through a minimally invasive approach were included. Surgical indications included intractable pain, mechanical instability, and neurologic compromise with radiologic visualization of the lesion.

RESULTS

20 patients with mean Tomita Score of 6.3 ± 2.1 points [95% CI, 5.3-7.2] were treated with constructs that spanned a mean of 4.7 ± 1.4 [95% CI, 4.0-5.3] instrumented levels. 10 (50%) patients were augmented with vertebroplasty. Majority of patients (65%) had no complications during their hospital stay and were discharged home (60%). Four patients received reoperation: two extracavitary corpectomies, one pathologic fracture at a different level, and one adjacent segment disease.

CONCLUSION

Minimally invasive PPSF is a safe and effective option when treating unstable neoplastic fractures and may be a viable alternative to the traditional open approach in select cases.

LEVEL OF EVIDENCE

4.

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.

Radical resection for solitary thoracic spinous-process metastasis: a case report and technical note

INTRODUCTION

Bone metastases confined to the posterior elements of the spine are rarely treated, as there exist no established radical surgical treatment options for this area. Herein, we present a case report of and technical note on a patient who underwent radical resection for a metastatic tumor in the thoracic spinous process.

CASE PRESENTATION

A 34-year-old male presented with a nasopharyngeal carcinoma with a solitary metastatic focus in the spinous process of the 10th thoracic vertebra. Imaging revealed that the tumor was confined to the spinous process and the surrounding soft tissues. No tumor was noted in the pedicles, vertebral body, and cortical bone on the ventral side of the lamina, as well as within the spinal canal. As treatment for this solitary metastatic lesion, we decided to perform radical resection with sufficient margins that would include the involved spinous process and all surrounding soft tissues exhibiting evidence of tumor infiltration. The posterior elements of the 9th-11th vertebrae, multifidus muscles, and skin were widely resected en bloc using a T-saw. The posterior elements of the spinal column were resected at the level of pedicles without full visualization of the involved dural sac. The tumor-infiltrated soft tissues surrounding the T10 vertebral spinous process were excised without full visualization of the tumor. Adjuvant therapy was not administered postoperatively. During the second year of follow-up, no signs of recurrence or metastasis were noted.

DISCUSSION

Our proposed technique allows wide resection of a solitary focus of metastasis in the posterior elements of the spine.

Predictive factors, preventive implications, and personalized surgical strategies for bone metastasis from lung cancer: population-based approach with a comprehensive cancer center-based study

Background

Bone metastasis (BM) and skeletal-related events (SREs) happen to advanced lung cancer (LC) patients without warning. LC-BM patients are often passive to BM diagnosis and surgical treatment. It is necessary to guide the diagnosis and treatment paradigm for LC-BM patients from reactive medicine toward predictive, preventive, and personalized medicine (PPPM) step by step.

Methods

Two independent study cohorts including LC-BM patients were analyzed, including the Surveillance, Epidemiology, and End Results (SEER) cohort (n = 203942) and the prospective Fudan University Shanghai Cancer Center (FUSCC) cohort (n = 59). The epidemiological trends of BM in LC patients were depicted. Risk factors for BM were identified using a multivariable logistic regression model. An individualized nomogram was developed for BM risk stratification. Personalized surgical strategies and perioperative care were described for FUSCC cohort.

Results

The BM incidence rate in LC patients grew (from 17.53% in 2010 to 19.05% in 2016). Liver metastasis was a significant risk factor for BM (OR = 4.53, 95% CI = 4.38-4.69) and poor prognosis (HR = 1.29, 95% CI = 1.25-1.32). The individualized nomogram exhibited good predictive performance for BM risk stratification (AUC = 0.784, 95%CI = 0.781-0.786). Younger patients, males, patients with high invasive LC, and patients with other distant site metastases should be prioritized for BM prevention. Spine is the most common site of BM, causing back pain (91.5%), pathological vertebral fracture (27.1%), and difficult walking (25.4%). Spinal surgery with personalized spinal reconstruction significantly relieved pain and improved daily activities. Perioperative inflammation, immune, and nutrition abnormities warrant personalized managements. Radiotherapy needs to be recommended for specific postoperative individuals.

Conclusions

The presence of liver metastasis is a strong predictor of LC-BM. It is recommended to take proactive measures to prevent BM and its SREs, particularly in young patients, males, high invasive LC, and LC with liver metastasis. BM surgery and perioperative management are personalized and required. In addition, adjuvant radiation following separation surgery must also be included in PPPM-guided management.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00270-9.

Clinical Outcome of Patients with Bone Metastases in a Convalescent Rehabilitation Ward: A Case Series of Six Patients

Background:

Advances in cancer treatment have led to an increase in the number of cancer survivors and, likewise, cancer patients in convalescent rehabilitation wards. It is difficult for patients with bone metastases to recover their motor functions and be discharged. However, cancer treatments, such as anti-cancer drug therapy and radiation therapy, are not generally provided in convalescent rehabilitation wards.

Cases:

This study retrospectively reviewed six cases of bone metastases in our convalescent rehabilitation ward from April 2018 to October 2019. The ages of the patients ranged from 58 to 85 years, and all patients were male. The primary cancers were lung cancer (two cases), renal cancer (one case), esophageal cancer (one case), prostate cancer (one case), and double lung and kidney cancer (one case). Bone metastases were observed in the spine (six cases), pelvis (two cases), and femur (one case). All patients were admitted to our convalescent rehabilitation ward for postoperative management of imminent fracture risk and rehabilitation of pathological fracture or spinal cord compression caused by bone metastasis. None of the patients received treatment for primary cancer or bone metastases during their hospitalization. Two patients had new bone metastases in load-bearing bones. Five patients were transferred to acute care hospitals for the treatment of cancer or infection.

Discussion:

Before transferring patients with bone metastases to convalescent rehabilitation wards, clinicians should assess the risk of skeletal-related events and the rate of progression of their cancer. Indications for hospitalization should be carefully determined in cooperation with acute care hospitals.

Risk factors for predicting cement leakage in percutaneous vertebroplasty for spinal metastases

BACKGROUND

The study aimed to identify the risk factors of cement leakage following percutaneous vertebroplasty for spinal metastases.

METHODS

230 consecutive patients with 530 vertebrae were retrospectively reviewed. Characteristics including age, primary cancer, location, pathological fracture, the integrity of the posterior wall, and the volume of bone cement were considered as potential risk factors. Cement leakage was evaluated by postoperative imaging examination and classified into three subtypes with different potential sequelae: spinal canal leakage, intravascular leakage around vertebrae, intradiscal and paravertebral leakage. Univariate and multivariate analyses were used to assess the risk factors.

RESULTS

Leakage was detected in 185 vertebrae (34.9%), 18.3% for intradiscal and paravertebral, 13.2% for intravascular around vertebrae, and 7.0% for spinal canal. Multivariate analysis showed that incomplete posterior wall (P = 0.001) and breast cancer (P = 0.015) were strong predictive factors for spinal canal leakage, incomplete posterior wall (P = 0.024) was for intravascular leakage around vertebrae, thoracic (P = 0.010) and pathological fracture (P = 0.000) were for intradiscal and paravertebral leakage.

CONCLUSIONS

Our findings suggest that cement leakage is common following percutaneous vertebroplasty for spinal metastases. The incomplete posterior wall is an unfavourable factor for intravascular leakage around vertebrae. Vertebrae with incomplete posterior wall and breast cancer metastases are more likely to develop spinal canal leakage.

The Oswestry Spinal Risk Index (OSRI) in assessing prognosis of patients with spinal metastases

Introduction

The Oswestry Spinal Risk Index (OSRI) was designed to predict life expectancy of patients presenting with spinal metastases. It integrates the most predictive items of existing scores and is calculated using not more than two items: General condition and primary tumor.

Research question

The purpose of this study was to externally validate the OSRI in a large cohort and to compare it with the established scores.

Material and methods

We retrospectively identified 211 consecutive surgical patients with symptomatic spinal metastases. We collected clinical and radiographic data, such as Karnofsky Performance Score (KPS), Frankel Status, primary tumor pathology and metastatic spread to calculate the Tokuhashi score, Tomita score, modified Bauer score and the OSRI. Logistic regression models, Kaplan-Meyer-curves, discriminant power and variance analyses were applied using Harrell’s C-index and Cox and Snell’s Pseudo R².

Results

Predicted and actual survival of our cohort’s patients correlated significantly in each investigated scoring systems (p < 0.001). In test quality measurements Tokuhashi score performed best (C = 0.7204; R² = 0.3619), followed by OSRI (C = 0.7023; R² = 0.2612), Tomita (C = 0.6748; R² = 0.2818) and modified Bauer score (C = 0.6653; R² = 0.2486). Accuracy of predicted life expectancy was highest in modified Bauer score and OSRI.

Discussion and conclusion

Compared to the original scores, the OSRI provided equal or even superior results in assessing our study population’s life expectancy. Its particular advantage lies in the simplicity of its application, which well meets the demands of surgical decision-making in daily practice.

•

Prognosis prediction in patients with spinal metastases.

•

Calculation of Oswestry Spinal Risk Index.

•

Comparison of prognosis scores in spinal metastases.

Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases

BACKGROUND CONTEXT

We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data.

PURPOSE

To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment.

PATIENT SAMPLE

We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019.

OUTCOME MEASURES

One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily.

METHODS

All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score.

RESULTS

When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score.

CONCLUSIONS

The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.

10-Year Trends in the Surgical Management of Patients with Spinal Metastases: A Scoping Review

BACKGROUND

Spinal metastases are present in approximately 20% of patients with cancer, giving a risk for neurologic dysfunction and instability. In already frail patients, surgeons strive to improve quality of life. Our goal was to review a 10-year trend in the surgical management of spinal metastases.

METHODS

A scoping review was performed systematically using PubMed to assess trends in surgical treatment for spinal metastases. The search terms used were: metastas∗, "neoplasm metastasis"[Mesh], "Spine"[Mesh], spine, spinal, "vertebral column," "vertebral body," laser, robot, radiofrequency, screws, fixation, "separation surgery," corpectomy, vertebrectomy, spondylectomy, vertebroplasty, kyphoplasty, surgery, "open surgery," "mini open surgery," "minimally invasive surgery," endoscopy, thoracoscopy, corpectom∗, vertebrectom∗, spondylectom∗, "en bloc," and MIS. The variables of interest were neurologic improvement, tumor recurrence, reoperation, and overall survival.

RESULTS

A total of 2132 articles were found within the primary query. Fifty-six studies were selected for final review. The results were organized into main surgical practices: decompression, mechanical stabilization, and pain management. For separation surgery, clinical outcomes were overall 1-year survival, 40.7%-78.4%; recurrence rate, 4.3%-22%; reoperation, 5%; and complications, 5.4%-14%. For corpectomy, clinical outcomes were overall 1-year survival, 30%-92%; reoperation, 1.1%-50%; and recurrence rate, of 1.1%-28%. Complications and reoperations with spinal instrumentation were 0%-13.6% and 0%-15%, respectively. Cement augmentation achieved pain reduction rates of 56%-100%, neurologic improvement/stability 84%-100%, and complication rates 6%-56%. Laser achieved local tumor control rate of 71%-82% at 1 year follow-up, reoperation rate of 15%-31%, and complication rate of 5%-26%.

CONCLUSIONS

Minimally invasive techniques for decompression and stabilization seem to be the preferred method to surgically treat metastatic spine disease, with good outcomes. More research with high level of evidence is required to support the long-term outcomes of these approaches.

Effectiveness of Rehabilitation for Cancer Patients with Bone Metastasis

Objectives:

Advances in cancer treatment have led to extended survival, and, as a result, the number of patients with bone metastases is increasing. Activities of daily living (ADL) decrease with bone metastasis and the need for rehabilitation is increasing. This study examined the effects of rehabilitation in patients with bone metastases.

Methods:

We retrospectively reviewed data of cancer patients with bone metastasis who received rehabilitation between 2016 and 2018. Efficacy of rehabilitation was evaluated in 92 patients as the change in the Functional Independence Measure (FIM) score divided by rehabilitation days (FIM change/day) and assessed by different metastatic sites.

Results:

Overall FIM scores significantly improved after rehabilitation. Moreover, FIM change/day improved in patients with pelvic metastases (n=44) more than in patients with other metastatic sites (n=48) (P=0.015). In FIM motor components, improvements in toilet, tub/shower, walk/wheelchair, and stairs were significantly greater in patients with pelvic metastasis than in those with other metastasis sites.

Conclusions:

Rehabilitation improved ADL status to a greater extent in patients with pelvic metastases than in those with other metastasis sites. Patients with pelvic metastases may fear fractures, limiting their ADL, but rehabilitation could eliminate this fear and improve FIM.

Quantified CIN Score From Cell-free DNA as a Novel Noninvasive Predictor of Survival in Patients With Spinal Metastasis

Purpose: Most currently available scores for survival prediction of patients with bone metastasis lack accuracy. In this study, we present a novel quantified CIN (Chromosome Instability) score modeled from cfDNA copy number variation (CNV) for survival prediction. Experimental Design: Plasma samples collected from 67 patients with bone metastases from 11 different cancer types between November 2015 and May 2016 were sent through low-coverage whole genome sequencing followed by CIN computation to make a correlation analysis between the CIN score and survival prognosis. The results were validated in an independent cohort of 213 patients. Results: During the median follow-up period of 598 (95% CI 364-832) days until December 25, 2018, 124 (44.3%) of the total 280 patients died. Analysis of the discovery dataset showed that CIN score = 12 was the optimal CIN cutoff. Validation dataset showed that CIN was elevated (score ≥12) in 87 (40.8%) patients, including 5 (5.75%) with head and neck cancer, 11 (12.6%) with liver and gallbladder cancer, 11 (12.6%) with cancer from unidentified sites, 21 (24.1%) with lung cancer, 7 (8.05%) with breast cancer, 4 (4.60%) with thyroid cancer, 6 (6.90%) with colorectal cancer, 4 (4.60%) with kidney cancer, 2 (2.30%) with prostate cancer, and 16 (18.4%) with other types of cancer. Further analysis showed that patients with elevated CIN were associated with worse survival (p < 0.001). For patients with low Tokuhashi score (≤8) who had predictive survival of less than 6 months, the CIN score was able to distinguish patients with a median overall survival (OS) of 443 days (95% CI 301-585) from those with a median OS of 258 days (95% CI 184-332). Conclusion: CNV examination in bone metastatic cancer from cfDNA is superior to the traditional predictive model in that it provides a noninvasive and objective method of monitoring the survival of patients with spine metastasis.

Estimating survival and choosing treatment for spinal metastases: Do spine surgeons agree with each other?

Purpose

This study aimed to investigate spine surgeons’ ability to estimate survival in patients with spinal metastases and whether survival estimates influence treatment recommendations.

Methods

60 Spine surgeons were asked a survival estimate and treatment recommendation in 12 cases. Intraclass correlation coefficients and descriptive statistics were used to evaluate variability, accuracy and association of survival estimates with treatment recommendation.

Results

There was substantial variability in survival estimates amongst the spine surgeons. Survival was generally overestimated, and longer estimated survival seemed to lead to more invasive procedures.

Conclusions

Prognostic models to estimate survival may aid surgeons treating patients with spinal metastases.

Freehand Minimally Invasive Pedicle Screw Fixation and Minimally Invasive Decompression for a Thoracic or Lumbar Vertebral Metastatic Tumor From Hepatocellular Carcinoma

Objective: To compare freehand minimally invasive pedicle screw fixation (freehand MIPS) combined with percutaneous vertebroplasty (PVP), minimally invasive decompression, and partial tumor resection with open surgery for treatment of thoracic or lumbar vertebral metastasis of hepatocellular carcinoma (HCC) with symptoms of neurologic compression, and evaluate its feasibility, efficacy, and safety.

Methods: Forty-seven patients with 1-level HCC metastatic thoracolumbar tumor and neurologic symptoms were included between February 2015 and April 2017. Among them, 21 patients underwent freehand MIPS combined with PVP, minimally invasive decompression, and partial tumor resection (group 1), while 26 patients were treated with open surgery (group 2). Duration of operation, blood loss, times of fluoroscopy, incision length, and stay in hospital were compared between the two groups. Pre- and postoperative visual analog scale (VAS) pain score, Oswestry Disability Index (ODI), American Spinal Injury Association (ASIA) grade, ambulatory status, and urinary continence were also recorded. The Cobb angle and central and anterior vertebral body height were measured on lateral radiographs before surgery and during follow-ups.

Results: Patients in group 1 showed significantly less blood loss (195.5 ± 169.1 ml vs. 873.1 ± 317.9 ml, P = 0.000), shorter incision length (3.4 ± 0.3 vs. 13.6 ± 1.8 cm, P = 0.000), shorter median stay in hospital (4–8/6 vs. 8–17/12 days, P = 0.000), more median times of fluoroscopy (5–11/6 vs. 4–7/5 times, P = 0.000), and longer duration of operation (204.8 ± 12.1 vs. 171.0 ± 12.0 min, P = 0.000) than group 2. Though VAS significantly decreased after surgery in both groups, VAS of group 1 was significantly lower than that of group 2 immediately after surgery and during follow-ups (P < 0.05). Similar results were found in ODI. No differences in the neurological improvement and spinal stability were observed between the two groups.

Conclusion: Freehand MIPS combined with PVP, minimally invasive decompression, and partial tumor resection is a safe, effective, and minimally invasive method for treating thoracolumbar metastatic tumors of HCC, with less blood loss, better pain relief, and shorter length of midline incision and stay in hospital.

Predictors of Nonelective Surgery for Spinal Metastases: Insights from a National Database

STUDY DESIGN

Secondary analysis of a national all-payer database.

OBJECTIVE

Our objectives were to identify patient- and hospital-level factors independently associated with the receipt of nonelective surgery and determine whether nonelective surgery portends differences in perioperative outcomes compared to elective surgery for spinal metastases.

SUMMARY OF BACKGROUND DATA

Spinal metastases may progress to symptomatic epidural spinal cord compression that warrants urgent surgical intervention. Although nonelective surgery for spinal metastases has been associated with poor postoperative outcomes, literature evaluating disparities in the receipt of nonelective versus elective surgery in this population is lacking.

METHODS

The National Inpatient Sample (2012-2015) was queried for patients who underwent surgical intervention for spinal metastases. Multivariable logistic regression models were constructed to evaluate the association of patient- and hospital-level factors with the receipt of nonelective surgery, as well as to evaluate the influence of admission status on perioperative outcomes.

RESULTS

After adjusting for disease-related factors and other baseline covariates, our multivariable logistic regression model revealed several sociodemographic differences in the receipt of nonelective surgery. Patients of black (odds ratio [OR] = 1.38, 95% confidence interval [CI]: 1.03-1.84, P = 0.032) and other race (OR = 1.50, 95% CI: 1.13-1.98, P = 0.005) had greater odds of undergoing nonelective surgery than their white counterparts. Patients of lower income (OR = 1.40, 95% CI: 1.06-1.84, P = 0.019) and public insurance status (OR = 1.56, 95% CI: 1.26-1.93, P < 0.001) were more likely to receive nonelective surgery than higher income and privately insured patients, respectively. Higher comorbidity burden was also associated with greater odds of non-elective admission (OR = 2.94, 95% CI: 2.07-4.16, P  < 0.001). With respect to perioperative outcomes, multivariable analysis revealed that patients receiving nonelective surgery were more likely to experience nonroutine discharge (OR = 2.50, 95% CI: 2.09-2.98, P  < 0.001) and extended length of stay [LOS] (OR = 2.45, 95% CI: 1.91-3.16, P < 0.001).

CONCLUSION

The present study demonstrates substantial disparities in the receipt of nonelective surgery across sociodemographic groups and highlights its association with nonroutine discharge and extended LOS.Level of Evidence: 3.

Comparison of three predictive scoring systems for morbidity in oncological spine surgery

Estimating complications in oncological spine surgery is challenging. The objective of this study was to compare the accuracy of three scoring systems for predicting perioperative morbidity after surgery for spinal metastases. One-hundred and five patients who underwent surgery between 2013 and 2019 were included in this study. All patients had scores retrospectively calculated using the New England Spinal Metastasis Score (NESMS), Metastatic Spinal Tumor Frailty Index (MSTFI), and Anzuategui scoring systems. The main outcome measure was development of a medical complication (minor or major) within 30 days of surgery. The predictive ability for each system was assessed using receiver operating characteristic analysis and calculations of the area under the curve (AUC). The average age for all patients was 61 years and 61/105 patients (58.1%) were male. The most common primary tumor origins were hematologic (23.8%), prostate (16.2%), breast (14.3%), and lung (13.3%). The overall 30-day complication rate was 36.2% and the rate of major complications was 21.9%. Among all patients who underwent oncological spine surgery, the NESMS score had the highest AUC for 30-day overall (AUC 0.64; 95% CI, 0.53 - 0.75) and major morbidity (AUC 0.68; 95% CI, 0.54- 0.81) in our population. However, the accuracy did not meet the threshold for clinical utility. Future prospective validation of these systems in other populations is encouraged.

COMPLICATIONS OF SURGICAL TREATMENT OF SPINAL METASTASES

ABSTRACT Objectives: To evaluate the complications of surgical treatment in a group of patients with spinal metastasis with epidural compression, undergoing surgical treatment. Methods: This is a comparative retrospective study (level of evidence III), which evaluated 96 patients with spinal metastases undergoing surgical treatment. Intra- and postoperative complications were obtained from the patients’ medical records and correlated with the following clinical characteristics: tumor type, tumor location, neurological deficit, age, number of affected vertebrae, Tokuhashi scale, Tomita scale, Karnofsky performance scale, and type of approach. Results: Complications of surgical treatment were observed in 29 (30.20%) patients. Surgical wound infection was the most frequent complication, observed in 15% of patients. Conclusions: Surgical treatment of spinal metastases presents complications in about 30% of patients and their occurrence should be considered in the treatment planning, weighing the risks and benefits for achieving the treatment goals. Level III evidence; Retrospective Study.

A Rare Manifestation of a Presumed Non-Osteophilic Brain Neoplasm: Extensive Axial Skeletal Metastases From Glioblastoma With Primitive Neuronal Components

Background

Glioblastoma multiforme (GBM) is the most common malignant tumor of the central nervous system. GBM with primitive neuronal component (GBM-PNC) is an aggressive variant identified in 0.5% of GBMs. Extracranial metastasis from GBM-PNC is a rare and challenging situation.

Methods

A special case of early-onset GBM with systemic bone metastasis was enrolled. Clinical data, including patient characteristics, disease course, and serial radiological images were retrieved and analyzed. Tumor tissues were obtained by surgical resections and were made into formalin-fixed paraffin-embedded sections. Histopathological examinations and genetic testing were performed for both the primary and metastatic tumor specimens.

Results

A 20-year-old man suffered from GBM with acute intratumoral hemorrhage of the left temporal lobe. He was treated by gross total resection and chemoradiotherapy following the Stupp protocol. Seven months later, he returned with a five-week history of progressive neck pain and unsteady gait. The radiographic examinations identified vertebral collapse at C4 and C6. Similar osteolytic lesions were also observed at the thoracolumbar spine, pelvic, and left femur. Anterior spondylectomy of C4 and C6 was performed. The resected vertebral bodies were infiltrated with greyish, soft, and ill-defined tumor tissue. One month later, he developed mechanical low-back pain and paraplegia caused by thoracolumbar metastases. Another spine surgery was performed, including T10 total en-bloc spondylectomy, T7-9, L2-3, and L5-S1 laminectomy. After the operation, the patient’s neurological function and spinal stability remained stable. However, he finally succumbed to the rapidly increased tumor burden and died 15 months from onset because of cachexia and multiple organ failure. In addition to typical GBM morphology, the histological examinations identified monomorphic small-round cells with positive immunohistochemical staining of synaptophysin and CD99, indicating the coexistence of PNC. The next-generation sequencing detected pathogenic mutations in TP53 and DNMT3A. Based on above findings, a confirmed diagnosis of systemic metastases from GBM-PNC (IDH-wild type, WHO grade IV) was made.

Conclusions

The present case highlights the occurrence and severity of extensive axial skeletal metastases from GBM-PNC. This rare variant of GBM requires aggressive multimodal treatment including surgery and chemoradiotherapy targeting PNC. The pathological screening of PNC is recommended in patients with early-onset GBM and intratumoral hemorrhage. Surgery for spinal metastasis is appropriate in patients with chemoradioresistance and relatively good general status, with the objectives of restoring spinal stability and relieving spinal cord compression.

Predictive value of hypoalbuminemia and severe hypoalbuminemia in oncologic spine surgery

STUDY DESIGN

Retrospective review of a prospectively collected national database.

OBJECTIVE

To evaluate the predictive value of hypoalbuminemia on outcomes in surgical spine oncology patients.

SUMMARY OF BACKGROUND DATA

It is well documented that patients with hypoalbuminemia (albumin <3.5) have significantly higher rates of surgical morbidity and mortality than patients with normal albumin (>3.5 g/dl). We evaluated outcomes for metastatic oncologic spine surgery patients based on pre-operative albumin levels.

MATERIALS AND METHODS

Patients who underwent surgery for metastatic spine disease were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. Three groups were established: patients with normal albumin (>3.5 g/dl), mild hypoalbuminemia (2.6 g/dl - 3.4 g/dl), and severe hypoalbuminemia (<=2.5 g/dl). A multivariate analysis was used to assess the association between albumin levels and mortality within 30 days of surgical intervention.

RESULTS

A total of 700 patients who underwent surgery for metastatic spinal disease and had pre-operative albumin levels available were identified; 64.0% had normal albumin (>3.5 g/dl), 29.6% had mild hypoalbuminemia, and 6.4% had severe hypoalbuminemia. The overall 30-day mortality was 7.6% for patients with normal albumin, 15.9% for patients with mild hypoalbuminemia, and 44.4% for patients with severe hypoalbuminemia. On multivariate analysis, patients with mild hypoalbuminemia (OR 1.7 95% CI: 1.0-3.0 p = 0.05) and severe hypoalbuminemia (OR 6.2 95% CI: 2.8-13.5 p < 0.001) were more likely to expire within 30 days compared to patients with preoperative albumin above 3.5 g/dl.

CONCLUSION

In this study, albumin level was found to be an independent predictor of 30-day mortality in patients who underwent operative intervention for metastatic spinal disease. Patients with severe hypoalbuminemia had a 7-fold increased risk when compared with those who had normal albumin. While these findings need to be validated by future studies, we believe they will prove useful for preoperative risk stratification and surgical decision-making.

Refractory recurrent spinal chondrosarcoma: What is the role of salvage surgery?

BACKGROUND

The spinal chondrosarcoma has high risk of recurrence if the initial surgery is not performed in an en bloc fashion. It remains technically demanding to surgically manage the refractory recurrent spinal chondrosarcoma (RRSC). This study is to assess the clinical features and investigate the prognostic factors for patients with RRSCs.

METHODS

forty-nine patients with RRSCs underwent salvage surgeries in our institution, and the clinical characteristics were collected and recorded by two independent reviewers. Univariate and multivariate analyses were performed to investigate the independent prognostic factors of recurrence-free survival (RFS) and overall survival (OS) for patients with RRSCs.

RESULTS

During the mean follow-up of 31.7 ± 21.04 months (Range 9-93), the 3-year RFS and OS rate was 24.5% and 34.5%, respectively. According to the Cox proportional hazards regression model, wide excision with tumor-free margin (>4 mm) was associated with both better RFS and OS for patients with RRSCs. Meanwhile, the number of recurrences ≤2 was beneficial to RFS, while high pathological grade was correlated with worse OS.

CONCLUSIONS

Wide excision with tumor-free margin (>4 mm) is recommendable if appropriate in the salvage surgery for patients with RRSCs. Patients with number of recurrences ≤ 2 and lower pathological grade may have better RFS and OS, respectively.

Open biopsy with posterior instrumentation followed by anterolateral approach for removal of an uncommon tumor in the cervical spine

The conventional treatment for the resection of cervical spinal tumors comprises anterior, posterior, and combined surgical approaches. However, these approaches have certain limitations when tumors invade the vertebrae, vertebral artery, or spinal nerves. Herein, we report an interesting case where a 45-year-old patient was admitted for neck pain. An invasive cervical spinal tumor was discovered and approached in two stages: stage 1 was open biopsy with posterior instrumentation, which was followed by stage 2 with an anterolateral approach for definitive surgical resection. A series of preoperative tests including angiography as well as a balloon occlusion test of the vertebral artery facilitated stage 2 surgical planning for gross total resection of the tumor while minimizing surgical complications.

Risk predictors of perioperative complications for the palliative surgical treatment of spinal metastasis

BACKGROUND

The complication rate for palliative surgery in spinal metastasis is relatively high, and major complications can impair the patient's activities of daily living. However, surgical indications are determined based primarily on the prognosis of the cancer, with the risk of complications not truly considered. We aimed to identify the risk predictors for perioperative complications in palliative surgery for spinal metastasis.

METHODS

A multicentered, retrospective review of 195 consecutive patients with spinal metastasis who underwent palliative surgeries with posterior procedures from 2001 to 2016 was performed. We evaluated the type and incidence of perioperative complications within 14 days after surgery. Patients were categorized into either the complication group (C) or no-complication group (NC). Univariate and multivariate analyses were used to identify potential predictors for perioperative complications.

RESULTS

Thirty patients (15%) experienced one or more complications within 14 days of surgery. The most frequent complications were surgical site infection (4%) and motor weakness (3%). A history of diabetes mellitus (C; 37%, NC; 9%: p < 0.01) and surgical time over 300 min (C; 27%, NC; 12%: p < 0.05) were significantly associated with complications according to univariate analysis. Increased blood loss and non-ambulatory status were determined to be potential risk factors. Of these factors, multivariate logistic regression revealed that a history of diabetes mellitus (OR: 6.6, p < 0.001) and blood loss over 1 L (OR: 2.7, p < 0.05) were the independent risk factors for perioperative complications. There was no difference in glycated hemoglobin A1c between the diabetes patients with and without perioperative complications.

CONCLUSIONS

Diabetes mellitus should be used for the risk stratification of surgical candidates regardless of the treatment status, and strict prevention of bleeding is needed in palliative surgeries with posterior procedures to mitigate the risk of perioperative complications.

Preliminary establishment of a spinal stability scoring system for multiple myeloma

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A comparison of two different surgical procedures in the treatment of isolated spinal metastasis patients with metastatic spinal cord compression: a case-control study

OBJECTIVE

The aim of the study was to compare total en bloc spondylectomy (TES) and separation surgery with postoperative stereotactic radiosurgery (SSRS) for isolated metastatic patients with spinal cord compression by assessing recurrence-free survival (RFS), overall survival (OS), postoperative complications, and quality of life scores (QoL).

METHODS

From October 2013 to December 2020, 52 isolated spinal metastasis patients with cord compression were selected and separated into two groups based on the surgical method used (TES group, n = 26; and SSRS group, n = 26). Indexes for evaluation included postoperative Frankel grade, postoperative ECOG-PS, RFS, OS, postoperative complications, operation time, intraoperative blood loss, and QoL.

RESULTS

The average follow-up duration was 31.44 months. There was no significant difference (P > 0.05) in postoperative complications and OS between the two groups. However, a significant difference in operation time, intraoperative blood loss, postoperative ECOG-PS, RFS, and mental health domain (6 months after surgery) was found between the two groups (P < 0.05). According to The Spine Oncology Study Group Outcomes Questionnaire assessment, the total pain and physical function domains scores were also elevated after surgery in both groups. However, no significant difference was observed between groups A and B (p = 0.450 and 0.446, respectively).

CONCLUSIONS

TES and SSRS were efficient methods for treating solitary spinal metastasis patients with metastatic spinal cord compression. Better local tumor control and mental health were found in the TES group, and most patients felt as if they were free of spinal tumors. Compared with TES, the SSRS caused less operation-related trauma. However, there was no significant difference in OS between the two groups.

Clinical Features and Serological Markers Risk Model Predicts Overall Survival in Patients Undergoing Breast Cancer and Bone Metastasis Surgeries

Background

Surgical therapy of breast cancer and bone metastasis can effectively improve the prognosis of breast cancer. However, after the first operation, the relationship between preoperative indicators and outcomes in patients who underwent metastatic bone surgery remained to be studied. Purpose 1. Recognize clinical and laboratory prognosis factors available to clinical doctors before the operation for bone metastatic breast cancer patients. 2. Develop a risk prediction model for 3-year postoperative survival in patients with breast cancer bone metastasis.

Methods

From 2014 to 2020, patients who suffered from breast cancer bone metastasis and received therapeutic procedures in our institution were included for analyses (n=145). For patients who underwent both breast cancer radical surgery and bone metastasis surgery, comprehensive datasets of the parameters of interest (clinical features, laboratory factors, and patient prognoses) were collected (n=69). We performed Multivariate Cox regression to identify factors that were associated with postoperative outcome. 3-year survival prediction model and nomograms were established by 100 bootstrapping. Its benefit was evaluated by calibration plot, C-index, and decision curve analysis. The Surveillance, Epidemiology, and End Results database was also used for external validation.

Results

Radiotherapy for primary cancer, pathological type of metastatic breast cancer, lymph node metastasis, elevated serum alkaline phosphatase, lactate dehydrogenase were associated with postoperative prognosis. Pathological types of metastatic breast cancer, multiple bone metastasis, organ metastases, and elevated serum lactate dehydrogenase were associated with 3-year survival. Then those significant variables and serum alkaline phosphatase counts were integrated to construct nomograms for 3-year survival. The C-statistic of the established predictive model was 0.83. The calibration plot presents a graphical representation of calibration. In the decision curve analysis, the benefits are higher than those of the extreme curve. The receiver operating characteristic of the external validation of the model was 0.82, indicating a favored fitting degree of the two models.

Conclusion

Our study suggests that several clinical features and serological markers can predict the overall survival among the patients who are about to receive bone metastasis surgery after breast cancer surgery. The model can guide the preoperative evaluation and clinical decision-making for patients. Level of evidence Level III, prognostic study.

Prognostic Factors Influencing Survival and a Treatment Pattern Analysis of Conventional Palliative Radiotherapy for Patients with Bone Metastases

BACKGROUND

Treatment indication for bone metastases is influenced by patient prognosis. Single-fraction radiotherapy (SFRT) was proven equally effective as multiple fractionation regimens (MFRT) but continues to be underused.

OBJECTIVE

Primary objectives: (a) to identify prognostic factors for overall survival and (b) to analyze treatment patterns of palliative radiotherapy (proportion of SFRT indication and predictive factors of radiotherapy regimen) for bone metastases.

METHODS

582 patients with bone metastases who underwent conventional radiotherapy between January 1st 2014-31 December 2017 were analyzed. The Cox proportional hazard model was used to identify predictors of overall survival. For the treatment pattern analysis, 677 radiotherapy courses were evaluated. The logistic regression model was used to identify potential predictors of radiotherapy regimen.

RESULTS

The 3-year overall survival was 15%. Prognostic factors associated with poor overall survival were multiple bone metastases [hazard ratio (HR = 5.4)], poor performance status (HR = 1.5) and brain metastases (HR = 1.37). SFRT prescription increased from 41% in 2017 to 51% in 2017. Predictors of SFRT prescription were a poor performance status [odds ratio (OR = 0.55)], lung (OR = 0.49) and urologic primaries (OR = 0.33) and the half-body lower site of irradiation (OR = 0.59). Spinal metastases were more likely to receive MFRT (OR = 2.09).

CONCLUSIONS

Based on the prognostic factors we identified, a selection protocol for patients candidates for palliative radiotherapy to bone metastases could be established, in order to further increase SFRT prescription in our institution.

Updated external validation of the SORG machine learning algorithms for prediction of ninety-day and one-year mortality after surgery for spinal metastasis

BACKGROUND CONTEXT

Surgical decompression and stabilization in the setting of spinal metastasis is performed to relieve pain and preserve functional status. These potential benefits must be weighed against the risks of perioperative morbidity and mortality. Accurate prediction of a patient's postoperative survival is a crucial component of patient counseling.

PURPOSE

To externally validate the SORG machine learning algorithms for prediction of 90-day and 1-year mortality after surgery for spinal metastasis.

STUDY DESIGN/SETTING

Retrospective, cohort study PATIENT SAMPLE: Patients 18 years or older at a tertiary care medical center treated surgically for spinal metastasis OUTCOME MEASURES: Mortality within 90 days of surgery, mortality within 1 year of surgery METHODS: This is a retrospective cohort study of 298 adult patients at a tertiary care medical center treated surgically for spinal metastasis between 2004 and 2020. Baseline characteristics of the validation cohort were compared to the derivation cohort for the SORG algorithms. The following metrics were used to assess the performance of the algorithms: discrimination, calibration, overall model performance, and decision curve analysis.

RESULTS

Sixty-one patients died within 90 days of surgery and 133 died within 1 year of surgery. The validation cohort differed significantly from the derivation cohort. The SORG algorithms for 90-day mortality and 1-year mortality performed excellently with respect to discrimination; the algorithm for 1-year mortality was well-calibrated. At both postoperative time points, the SORG algorithms showed greater net benefit than the default strategies of changing management for no patients or for all patients.

CONCLUSIONS

With an independent, contemporary, and geographically distinct population, we report successful external validation of SORG algorithms for preoperative risk prediction of 90-day and 1-year mortality after surgery for spinal metastasis. By providing accurate prediction of intermediate and long-term mortality risk, these externally validated algorithms may inform shared decision-making with patients in determining management of spinal metastatic disease.