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Seok SY, Cho JH, Lee HR, Park JW, Park JH, Lee DH, Hwang CJ, Park S, Jang HJ. The Perioperative Effects of Preoperative Radiotherapy in Metastatic Spinal Tumor Patients. World Neurosurg 2024; 188:e273-e277. [PMID: 38777324 DOI: 10.1016/j.wneu.2024.05.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Radiotherapy is one of the important treatment options for metastatic spinal tumors but is not the definite intervention in all cases, as there are patients who still require surgical treatment because of severe pain or neurologic events after this treatment. We evaluated the perioperative effects of preoperative radiotherapy in these cases as a future guide for surgeons on critical considerations in this period. METHODS We included 328 patients in this study who had undergone decompression and fusion surgery for metastatic spinal tumors. Patients who underwent surgery with preoperative radiotherapy were designated as the radiotherapy group (group RT, n = 81), and cases of surgery without preoperative radiotherapy were assigned to the non-radiotherapy group (group nRT, n = 247). We compared the demographic, intraoperative, and postoperative factors between these 2 groups. RESULTS In terms of intraoperative factors, statistically significant differences were evident in operation time, estimated blood loss, and transfusion (RT vs. nRT: 188.1 ± 80.7 minutes vs. 231.2 ± 106.1 minutes, 607.2 ± 532.7 mL vs. 830.1 ± 1324.7 mL, and 30.9% vs. 43.3%, P < 0.001, P < 0.031, and P < 0.048, respectively). With regard to postoperative factors, the incidence of infection, wound problems, and local recurrence were statistically higher in group RT (RT vs. nRT: 6.2% vs. 0.8%, 12.3% vs. 0.8%, 23.4% vs. 13.7%, P = 0.004, P < 0.001, and P = 0.038, respectively). CONCLUSIONS Preoperative radiotherapy has the intraoperative advantages of reducing bleeding and shortening the operating time, but postoperative caution is needed because of the possibility of infection, wound problems, and local recurrence increases.
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Affiliation(s)
- Sang Yun Seok
- Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Jae Hwan Cho
- Department of Orthopaedic Surgery, Seoul Asan Medical Center, Ulsan University School of Medicine, Seoul, South Korea.
| | - Hyung Rae Lee
- Department of Orthopaedic Surgery, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, South Korea
| | - Jae Woo Park
- Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung-si, South Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Seoul Asan Medical Center, Ulsan University School of Medicine, Seoul, South Korea
| | - Dong-Ho Lee
- Department of Orthopaedic Surgery, Seoul Asan Medical Center, Ulsan University School of Medicine, Seoul, South Korea
| | - Chang Ju Hwang
- Department of Orthopaedic Surgery, Seoul Asan Medical Center, Ulsan University School of Medicine, Seoul, South Korea
| | - Sehan Park
- Department of Orthopaedic Surgery, Seoul Asan Medical Center, Ulsan University School of Medicine, Seoul, South Korea
| | - Ha Jun Jang
- Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
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Martín Benlloch A, Bolós Ten L, Morales Codina AM. [Translated article] Vertebral metastases. En bloc treatment. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:S560-S575. [PMID: 37774916 DOI: 10.1016/j.recot.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023] Open
Abstract
En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilisation techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimise outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.
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Affiliation(s)
- A Martín Benlloch
- Unidad de Patología Compleja y Tumoral del Adulto, Hospital Universitario Dr. Peset, Valencia, Spain; Departamento de Cirugía, Universidad de Valencia, Valencia, Spain.
| | - L Bolós Ten
- Unidad de Columna A. Martín, Hospital Vithas Valencia 9 de Octubre, Valencia, Spain
| | - A M Morales Codina
- Unidad de Patología Compleja y Tumoral del Adulto, Hospital Universitario Dr. Peset, Valencia, Spain
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Martín Benlloch A, Bolós Ten L, Morales Codina AM. Vertebral metastases. En bloc treatment. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:560-575. [PMID: 37689353 DOI: 10.1016/j.recot.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023] Open
Abstract
En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilization techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimize outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.
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Affiliation(s)
- A Martín Benlloch
- Unidad de Patología Compleja y Tumoral del Adulto, Hospital Universitario Dr. Peset, Valencia, España; Departamento de Cirugía, Universidad de Valencia, Valencia, España.
| | - L Bolós Ten
- Unidad de Columna A. Martín, Hospital Vithas Valencia 9 de Octubre, Valencia, España
| | - A M Morales Codina
- Unidad de Patología Compleja y Tumoral del Adulto, Hospital Universitario Dr. Peset, Valencia, España
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Jarvers JS, Lange M, Schiemann S, Pfränger J, Heyde CE, Osterhoff G. Risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative radiation therapy. BMC Surg 2021; 21:423. [PMID: 34920720 PMCID: PMC8684154 DOI: 10.1186/s12893-021-01431-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advancements in the field of oncological therapies during the last decades have led to a significantly prolonged survival of cancer patients. This has led to an increase in the incidence of spinal metastases. The purpose of this study was to assess risk factors for wound-related complications after surgical stabilization of spinal metastases with a special focus on the effect of postoperative RT and its timing. METHODS Patients who had been treated for metastatic spine disease by surgical stabilization followed by radiotherapy between 01/2012 and 03/2019 were included and a retrospective chart review was performed. RESULTS Of 604 patients who underwent stabilizing surgery for spinal metastases, 237 patients (mean age 66 years, SD 11) with a mean follow-up of 11 months (SD 7) were eligible for further analysis. Forty-one patients (17.3%) had wound-related complications, 32 of them before and 9 after beginning of the RT. Revision surgery was necessary in 26 patients (11.0%). Body weight (p = 0.021), obesity (p = 0.018), ASA > 2 (p = 0.001), and start of radiation therapy within 21 days after surgery (p = 0.047) were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of surgery (12%) were more likely to have a wound-related surgical revision (p = 0.031). CONCLUSION Body weight, obesity and ASA > 2 were associated with an increased risk for wound complications. Patients with chemotherapy within 3 weeks of the surgery were more likely to have a wound-related revision surgery. Patients who had begun radiation therapy within 21 days after surgery were more likely to have a wound complication compared to patients who waited longer.
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Affiliation(s)
- Jan-Sven Jarvers
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Maximilian Lange
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Samuel Schiemann
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Jan Pfränger
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany.
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5
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Spinal metastasis: The rise of minimally invasive surgery. Surgeon 2021; 20:328-333. [PMID: 34563452 DOI: 10.1016/j.surge.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Bone is the third most common site of metastatic cancer, of which the spine is the most frequently involved. As metastatic cancer prevalence rises and surgical techniques advance, operative intervention for spinal metastases is expected to rise. In the first operative cohort of spinal metastasis in Ireland, we describe the move towards less invasive surgery, the causative primary types and post-operative survival. METHODS This is a retrospective cohort study of all operative interventions for spinal metastasis in a tertiary referral centre over eight years. Primary spinal tumours and local invasion to the spine were excluded. Median follow up was 1895 days. RESULTS 225 operative procedures in 196 patients with spinal metastasis were performed over eight years. Average cases per year increased form 20 per year to 29 per year. Percutaneous procedures became more common, accounting for the majority (53%) in the final two years. The most common primary types were breast, myeloma, lung, prostate and renal. Overall survival at 1 year was 51%. Primary type was a major determinant of survival, with breast and the haematological cancers demonstrating good survival, while lung had the worst prognosis. CONCLUSION This is the first descriptive cohort of operative interventions for spinal metastasis in an Irish context. Surgery for spinal metastasis is performed at an increasing rate, especially through minimally-invasive means. The majority of patients survive for at least one year post-operatively. Prudent resource planning is necessary to prepare for this growing need.
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Furlan JC, Wilson JR, Massicotte EM, Sahgal A, Michael FG. Recent advances and new discoveries in the pipeline of the treatment of primary spinal tumors and spinal metastases: A scoping review. Neuro Oncol 2021; 24:1-13. [PMID: 34508647 DOI: 10.1093/neuonc/noab214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The field of spinal oncology has substantially evolved over the past decades. This review synthesizes and appraises what was learned and what will potentially be discovered from the recently completed and ongoing clinical studies related to the treatment of primary and secondary spinal neoplasms. This scoping review included all clinical studies on the treatment of spinal neoplasms registered in the ClinicalTrials.gov website from February/2000 to December/2020. The terms "spinal cord tumor", "spinal metastasis", and "metastatic spinal cord compression" were used. Of the 174 registered clinical studies on primary spinal tumors and spinal metastasis, most of the clinical studies registered in this American registry were interventional studies led by single institutions in North America (n=101), Europe (n=43), Asia (n=24) or other continents (n=6). The registered clinical studies mainly focused on treatment strategies for spinal neoplasms (90.2%) that included investigating stereotactic radiosurgery (n=33), radiotherapy (n=21), chemotherapy (n=20), and surgical technique (n=11). Of the 69 completed studies, the results from 44 studies were published in the literature. In conclusion, this review highlights the key features of the 174 clinical studies on spinal neoplasms that were registered from 2000 to 2020. Clinical trials were heavily skewed towards the metastatic population as opposed to the primary tumours which likely reflects the rarity of the latter condition and associated challenges in undertaking prospective clinical studies in this population. This review serves to emphasize the need for a focused approach to enhancing translational research in spinal neoplasms with a particular emphasis on primary tumors.
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Affiliation(s)
- Julio C Furlan
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,KITE Research Institute, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,St. Michael's Hospital, Toronto, Ontario, Canada
| | - Eric M Massicotte
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Ontario, Canada
| | - Fehlings G Michael
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Pahuta MA, Fisk F, Versteeg AL, Fisher CG, Sahgal A, Gokaslan ZL, Reynolds JJ, Laufer I, Lazary A, Rhines LD, Boriani S, Bettegowda C, Dea N. Calculating Utilities From the Spine Oncology Study Group Outcomes Questionnaire: A Necessity for Economic and Decision Analysis. Spine (Phila Pa 1976) 2021; 46:1165-1171. [PMID: 34334684 PMCID: PMC8357033 DOI: 10.1097/brs.0000000000003981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN General population utility valuation study. OBJECTIVE The aim of this study was to develop a technique for calculating utilities from the Spine Oncology Study Group Outcomes Questionnaire v2.0 (SOSGOQ2.0). SUMMARY OF BACKGROUND DATA The ability to calculate quality-adjusted life-years (QALYs) for metastatic spine disease would enhance treatment decision-making and facilitate economic analysis. QALYs are calculated using utilities. METHODS Using a hybrid concept-retention and factorial analysis shortening approach, we first shortened the SOSGOQ2.0 to eight items (SOSGOQ-8D). This was done to lessen the cognitive burden of the utility valuation exercise. A general population sample of 2730 adults was then asked to evaluate 12 choice sets based on SOSGOQ-8D health states in a Discrete Choice Experiment. A utility scoring rubric was then developed using a mixed multinomial-logit regression model. RESULTS We were able to reduce the SOSGOQ2.0 to an SOSGOQ-8D with a mean error of 0.003 and mean absolute error of 3.078 compared to the full questionnaire. The regression model demonstrated good predictive performance and was used to develop a utility scoring rubric. Regression results revealed that participants did not regard all SOSGOQ-8D items as equally important. CONCLUSION We provide a simple technique for converting the SOSGOQ2.0 to utilities. The ability to evaluate QALYs in metastatic spine disease will facilitate economic analysis and patient counseling. We also quantify the importance of individual SOSGOQ-8D items. Clinicians should heed these findings and offer treatments that maximize function in the most important items.Level of Evidence: 3.
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Affiliation(s)
- Markian A. Pahuta
- Division of Orthopedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Felicity Fisk
- Department of Orthopedics, Henry Ford Health System, Detroit, MI
| | - Anne L. Versteeg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands and Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Charles G. Fisher
- Division of Spine, Surgery Vancouver Spine Surgery Institute, Vancouver General Hospital University of British Columbia, Vancouver, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center and University of Toronto, Toronto, Ontario, Canada
| | - Ziya L. Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital and The Miriam Hospital, Providence, RI
| | | | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY
| | - Aron Lazary
- National Center for Spinal Disorders and Buda Health Center, Budapest, Hungary
| | - Laurence D. Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stefano Boriani
- Spine Surgery Division, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nicolas Dea
- Division of Spine, Surgery Vancouver Spine Surgery Institute, Vancouver General Hospital University of British Columbia, Vancouver, Canada
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Dea N, Versteeg AL, Sahgal A, Verlaan JJ, Charest-Morin R, Rhines LD, Sciubba DM, Schuster JM, Weber MH, Lazary A, Fehlings MG, Clarke MJ, Arnold PM, Boriani S, Bettegowda C, Laufer I, Gokaslan ZL, Fisher CG. Metastatic Spine Disease: Should Patients With Short Life Expectancy Be Denied Surgical Care? An International Retrospective Cohort Study. Neurosurgery 2021; 87:303-311. [PMID: 31690935 PMCID: PMC7360875 DOI: 10.1093/neuros/nyz472] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite our inability to accurately predict survival in many cancer patients, a life expectancy of at least 3 mo is historically necessary to be considered for surgical treatment of spinal metastases. OBJECTIVE To compare health-related quality of life (HRQOL) in patients surviving <3 mo after surgical treatment to patients surviving >3 mo to assess the validity of this inclusion criteria. METHODS Patients who underwent surgery for spinal metastases between August 2013 and May 2017 were retrospectively identified from an international cohort study. HRQOL was evaluated using generic and disease-specific outcome tools at baseline and at 6 and 12 wk postsurgery. The primary outcome was the HRQOL at 6 wk post-treatment measured by the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ). RESULTS A total of 253 patients were included: 40 patients died within the first 3 mo after surgery and 213 patients survived more than 3 mo. Patients surviving <3 mo after surgery presented with lower baseline performance status. Adjusted analyses for baseline performance status did not reveal a significant difference in HRQOL between both groups at 6 wk post-treatment. No significant difference in patient satisfaction at 6 wk with regard to their treatment could be detected between both groups. CONCLUSION When controlled for baseline performance status, quality of life 6 wk after surgery for spinal metastasis is independent of survival. To optimize improvement in HRQOL for this patient population, baseline performance status should take priority over expected survival in the surgical decision-making process.
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Affiliation(s)
- Nicolas Dea
- Division of Spine Surgery, Department of Orthopaedics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Anne L Versteeg
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Canada
| | - Jorrit-Jan Verlaan
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raphaële Charest-Morin
- Division of Spine Surgery, Department of Orthopaedics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Laurence D Rhines
- MD Anderson Cancer Center, Department of Neurosurgery, The University of Texas, Houston, Texas
| | - Daniel M Sciubba
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael H Weber
- Division of Surgery, Montreal General Hospital, McGill University, Montreal, Canada
| | - Aron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
| | - Michael G Fehlings
- Spine Program, Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | | | - Paul M Arnold
- Department of Neurosurgery, The University of Kansas Hospital, The University of Kansas, Kansas City, Kansas
| | | | - Chetan Bettegowda
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Miriam Hospital, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island.,Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Brown University, Providence, Rhode Island
| | - Charles G Fisher
- Division of Spine Surgery, Department of Orthopaedics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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Azad TD, Varshneya K, Herrick DB, Pendharkar AV, Ho AL, Stienen M, Zygourakis C, Bagshaw HP, Veeravagu A, Ratliff JK, Desai A. Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease. Global Spine J 2021; 11:44-49. [PMID: 32875859 PMCID: PMC7734271 DOI: 10.1177/2192568219889363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN This was an epidemiological study using national administrative data from the MarketScan database. OBJECTIVE To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease. METHODS We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes. RESULTS A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574). CONCLUSIONS When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.
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Affiliation(s)
- Tej D. Azad
- Stanford University School of Medicine, Stanford, CA, USA
- Tej D. Azad and Kunal Varshneya contributed equally toward this study
| | - Kunal Varshneya
- Stanford University School of Medicine, Stanford, CA, USA
- Tej D. Azad and Kunal Varshneya contributed equally toward this study
| | | | | | - Allen L. Ho
- Stanford University School of Medicine, Stanford, CA, USA
| | - Martin Stienen
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Atman Desai
- Stanford University School of Medicine, Stanford, CA, USA
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Spine and Non-spine Bone Metastases - Current Controversies and Future Direction. Clin Oncol (R Coll Radiol) 2020; 32:728-744. [PMID: 32747153 DOI: 10.1016/j.clon.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
Bone is a common site of metastases in advanced cancers. The main symptom is pain, which increases morbidity and reduces quality of life. The treatment of bone metastases needs a multidisciplinary approach, with the main aim of relieving pain and improving quality of life. Apart from systemic anticancer therapy (hormonal therapy, chemotherapy or immunotherapy), there are several therapeutic options available to achieve palliation, including analgesics, surgery, local radiotherapy, bone-seeking radioisotopes and bone-modifying agents. Long-term use of non-steroidal analgesics and opiates is associated with significant side-effects, and tachyphylaxis. Radiotherapy is effective mainly in localised disease sites. Bone-targeting radionuclides are useful in patients with multiple metastatic lesions. Bone-modifying agents are beneficial in reducing skeletal-related events. This overview focuses on the role of surgery, including minimally invasive treatments, conventional radiotherapy in spinal and non-spinal bone metastases, bone-targeting radionuclides and bone-modifying agents in achieving palliation. We present the clinical data and their associated toxicity. Recent advances are also discussed.
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Kumar N, Madhu S, Bohra H, Pandita N, Wang SSY, Lopez KG, Tan JH, Vellayappan BA. Is there an optimal timing between radiotherapy and surgery to reduce wound complications in metastatic spine disease? A systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:3080-3115. [DOI: 10.1007/s00586-020-06478-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
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12
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LUGÃO ARIELFALBEL, SILVEIRA JUNIOR CLOVISCASTANHO, TEIXEIRA WILLIAMGEMIOJACOBSEN, CRISTANTE ALEXANDREFOGAÇA. THE SINS SCALE IN THE EVALUATION OF STABILITY IN PATIENTS WITH SPINAL METASTASIS. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201902224003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective To evaluate the distribution of patients seen in the emergency care unit of the Instituto do Câncer do Estado de São Paulo in the categories “stable”, “indeterminate” and “unstable” as classified by the SINS scale. Methods The medical charts of patients treated between May and September 2013 were reviewed. Patients with a diagnosis of spinal metastasis were analyzed and data on age, sex, primary tumor location, neurological status, and the presence and intensity of pain at rest and in movement were obtained. The SINS criteria were used to evaluate the radiological involvement of the spine. Results We included 81 patients with a mean age of 59.57 years; 32 (39.51%) men and 49 (60.49%) women. Breast (19.75%), prostate (18.52%) and lung (17.28%) were the most common primary tumor sites. Only 18 patients (22.22%) had a single lesion and 51 (62.96%) had 3 or more metastatic lesions. Of the total, 56 (69.14%) were of undetermined stability, 19 were stable (23.46%) and 6 were unstable (7.41%). Twenty-two (27.2%) presented neurological deficit in the physical examination. None of the patients with severe deficit, Frankel A or B, were stable according to the SINS classification. All unstable lesions presented with kyphotic and/or scoliotic deviation (p <0.001). Most patients with undetermined lesions (78.6%) and all patients with unstable lesions had mechanical pain (p = 0.001). Conclusion In this case series, there was a high rate of patients classified by the SINS scale as of undetermined instability (69.14%). There was a high number of patients with multiple metastases (62.96%), which was not considered a modifier of the SINS instability criteria and which needs to be the focus of future studies. Level of evidence IV; Case Series.
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Affiliation(s)
- ARIEL FALBEL LUGÃO
- Universidade de São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Brazil
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Xu C, Yin M, Sun Z, Yan Y, Mo W, Yan W. An Independent Interobserver Reliability and Intraobserver Reproducibility Evaluation of Spinal Instability Neoplastic Score and Kostuik Classification Systems for Spinal Tumor. World Neurosurg 2020; 137:e564-e569. [PMID: 32068169 DOI: 10.1016/j.wneu.2020.02.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most patients with spinal tumors suffer no symptoms or have mild symptoms, but about 14% of patients have refractory pain caused by mechanical instability, or symptoms of spinal cord damage caused by epidural spinal cord compression. The Spinal Instability Neoplastic Score (SINS) and Kostuik classification are commonly used to evaluate spinal stability, and help to make a more detailed operation plan. The objectives of this study are to evaluate the reliability and reproducibility of the SINS and Kostuik classification, and to explore their clinical application value. METHODS All 80 patients with spinal tumors were enrolled. Six spine surgeons who have certain clinical experience were selected. Patients were scored according to the SINS scoring system and classification was determined according to the Kostuik system. We used Fleiss and Cohen κ values to check the coefficient consistency for multifactors. We used Cohen κ value to check the interobserver reliability and intraobserver reproducibility. After 12 weeks, we repeated the analysis. RESULTS The interobserver reliability and intraobserver reproducibility of the SINS scoring system were near perfect with values of 0.831 and 0.874, respectively. The interobserver reliability and intraobserver reproducibility of the Kostuik classification system were moderate with values of 0.505 and 0.595, respectively. CONCLUSIONS Compared with the Kostuik classification system, the SINS scoring system has better interobserver reliability and intraobserver reproducibility, which can be widely used in clinical practice and has great significance in the decision-making of spinal tumor treatment. Although the Kostuik classification system is often used in clinical practice, it shows inferior reliability and reproducibility in our study.
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Affiliation(s)
- Chongqing Xu
- Department of Orthopaedics, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengchen Yin
- Department of Orthopaedics, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhengwang Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Yinjie Yan
- Department of Orthopaedics, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wen Mo
- Department of Orthopaedics, LongHua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wangjun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.
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14
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Roser S, Maharaj MM, Taylor MA, Kuru R, Hansen MA, Ferch R. Vertebrectomy in metastatic spinal tumours: A 10 year, single-centre review of outcomes and survival. J Clin Neurosci 2019; 68:218-223. [PMID: 31331749 DOI: 10.1016/j.jocn.2019.04.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/03/2019] [Accepted: 04/28/2019] [Indexed: 11/17/2022]
Abstract
Metastatic disease to the vertebral column can cause spinal instability, neurological deterioration and pain. The present study was designed to provide insight into the cohort undergoing vertebrectomy for metastatic disease to the spinal column, assessing the associated morbidity, functional outcomes and survival. A retrospective review of 141 consecutive vertebrectomies for metastatic disease was undertaken. The procedures were performed between 2006 and 2016 at a single institution. Medical records were reviewed and data was obtained regarding primary malignancy, presenting symptoms, pre-operative chemotherapy or radiotherapy, Spinal Instability Neoplastic Score, neurological function, operative approach and duration, blood loss, transfusion requirement, complications, survival, delayed neurological deterioration and construct failure. Long-term follow-up data was available for 123 patients. Forty-two patients were alive at the time of review with a mean survival of 464 days. Post-operative neurological function was preserved or improved in 96.5% of patients. Five patients suffered a neurological deterioration post-operatively. The major complication rate was 19.8% with the most frequent complication being wound infection or dehiscence requiring revision. There were four inpatient deaths. Mean operative time was 240 min. Mean blood loss was 1490 mls. When assessing results by age, no significant difference with respect to complications, neurological outcomes or survival was demonstrated in patients over age 65. There was a significant reduction in survival and higher complication rates in patients who were non-ambulatory following vertebrectomy. Vertebrectomy is a safe and effective means of providing circumferential neural decompression and stabilization with an acceptable complication rate in patients with vertebral metastases, irrespective of age.
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Affiliation(s)
- Sophia Roser
- Department of Neurosurgery, John Hunter Hospital, New Lambton, Australia.
| | - Monish M Maharaj
- Resident Medical Officer, Prince of Wales Hospital, Randwick, Australia
| | - Michael A Taylor
- Resident Medical Officer, John Hunter Hospital, New Lambton, Australia
| | - Rob Kuru
- Department of Orthopaedic Surgery, John Hunter Hospital, New Lambton, Australia
| | - Mitchell A Hansen
- Department of Neurosurgery, John Hunter Hospital, New Lambton, Australia
| | - Richard Ferch
- Department of Neurosurgery, John Hunter Hospital, New Lambton, Australia
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15
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Yahanda AT, Buchowski JM, Wegner AM. Treatment, complications, and outcomes of metastatic disease of the spine: from Patchell to PROMIS. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:216. [PMID: 31297381 DOI: 10.21037/atm.2019.04.83] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Spinal metastases are common in patients with cancer. As cancer treatments improve and these patients live longer, the number who present with metastatic spine disease will increase. Treatment strategies for these patients continues to evolve. In particular, since the prospective randomized controlled study in 2005 by Patchell et al. showed increased survival with decompressive surgical treatment of spinal metastases, there is a growing body of literature focusing on surgical management and complications of surgery for this disease. Surgery is often one component of a multimodal treatment approach with chemotherapy and radiation, which makes it difficult to parse the benefits of each individual treatment in outcome studies. Additionally, there has been more recent emphasis placed on patient-reported outcomes (PRO) after treatment for metastatic spine disease. In this review, we summarize treatments of metastatic spinal disease, possible perioperative complications, and validated tools used to assess outcomes for these patients.
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Affiliation(s)
- Alexander T Yahanda
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Jacob M Buchowski
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Adam M Wegner
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri, USA
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Lee RS, Batke J, Weir L, Dea N, Fisher CG. Timing of surgery and radiotherapy in the management of metastatic spine disease: expert opinion. JOURNAL OF SPINE SURGERY 2018; 4:368-373. [PMID: 30069530 DOI: 10.21037/jss.2018.05.05] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Combined surgery and radiotherapy, in the treatment of metastatic disease of the spine, is now emerging as the gold standard of care where there is an indication for spinal stabilization and/or surgical decompression. However potential complications related to wound healing can occur with radiation delivered shortly before or after to surgery. The purpose of this study was to understand the practice of leading radiation oncologists and spine surgeons with regards to the timing of radiation (conventional and stereotactic) and surgery for the management of spinal metastases. Methods Questionnaires were sent to leading radiation oncologists and spine surgeons throughout North America and completed via mail, email or internet. Results Eighty-six responses were received from radiation oncologists and 27 from spine surgeons. A total of 58% recommended waiting either 1 or 2 weeks after radiotherapy before operating on patients with spinal metastases. With radiotherapy administered after surgery, 62% of respondents suggested either a 1 or 2 weeks interval was sufficient. Conclusions There appeared to be no significant difference in practice with the use of stereotactic radiotherapy though surgeons tend to accept a shorter interval in this subset of patients. We recommend that the interval between radiotherapy and surgery (and vice versa) should ideally be a minimum of 2 weeks.
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Affiliation(s)
- Robert S Lee
- Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - Juliet Batke
- Regional Surgical Program, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Lorna Weir
- British Columbia Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Charles G Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia, and the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Assessing the utility of the spinal instability neoplastic score (SINS) to predict fracture after conventional radiation therapy (RT) for spinal metastases. Pract Radiat Oncol 2018; 8:e285-e294. [PMID: 29703703 DOI: 10.1016/j.prro.2018.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE Assessing the stability of spinal metastases is critical for making treatment decisions. The spinal instability neoplastic score (SINS) was developed by the Spine Oncology Study Group to categorize tumor-related lesions; however, data describing its utility in predicting fractures in patients with spinal metastases are limited. The purpose of this study is to assess the validity of SINS in predicting new or worsening fracture after radiation therapy (RT) to spine metastases. METHODS AND MATERIALS This is a retrospective analysis of patients treated with conventional RT alone (median total dose, 30 Gy; range, 8-47 Gy; median number of fractions, 10; range, 1-25) for spinal metastasis at Dana-Farber/Brigham and Women's Cancer Center from 2006 to 2013. SINS was calculated for each lesion (range, 0-18). The primary endpoint was time from RT start to radiographically documented new or worsening fracture or last disease assessment. RESULTS A total of 203 patients and 250 lesions were included in analysis. The percentages of lesions with SINS of 0 to 6, 7 to 12, and 13 to 18 were 38.8%, 54.8%, and 6.4%, respectively. Of 250 lesions, 20.4% developed new or worsening fractures; 14.4% for SINS 0 to 6, 21.2% for SINS 7 to 12, and 50.0% for SINS 13 to 18. Multivariate analysis adjusted for sex, age, Eastern Cooperative Oncology Group, histology, and total dose indicated that, compared with stable lesions (SINS 0-6), potentially unstable lesions (SINS 7-12) demonstrated a greater likelihood of new or worsening fracture that was not statistically significant (hazard ratio, 1.66; 95% confidence interval, 0.85-3.22; P = .14), and unstable lesions (SINS 13-18) were significantly more likely to develop to new or worsening fracture (hazard ratio, HR,4.37, 95% confidence interval, 1.80-10.61; P = .001). CONCLUSIONS In this study of patients undergoing RT for spinal metastases, 20.4% developed new or worsening vertebral fractures. SINS is demonstrated to be a useful tool to assess fracture risk after RT.
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18
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Turner I, Kennedy J, Morris S, Crockard A, Choi D. Surgery and Radiotherapy for Symptomatic Spinal Metastases Is More Cost Effective Than Radiotherapy Alone: A Cost Utility Analysis in a U.K. Spinal Center. World Neurosurg 2018; 109:e389-e397. [DOI: 10.1016/j.wneu.2017.09.189] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Optimizing the Adverse Event and HRQOL Profiles in the Management of Primary Spine Tumors. Spine (Phila Pa 1976) 2016; 41 Suppl 20:S212-S217. [PMID: 27753783 DOI: 10.1097/brs.0000000000001821] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVE To investigate if evidence-based principles of oncologic resection for primary spinal tumors are correlated with an acceptable morbidity and mortality profile and satisfactory health-related quality of life (HRQOL) measures. SUMMARY OF BACKGROUND DATA Respecting oncologic principles for primary spinal tumor surgery is correlated with lower recurrence rates. These interventions are, however, often highly morbid. METHODS A systematic literature review was performed to address the objectives by searching MEDLINE and EBMR databases. Articles that met our inclusion criteria were reviewed. GRADE guidelines were used for recommendation formulation. RESULTS A total of 25 articles addressing the morbidity and mortality profile of primary spinal tumor surgery were identified. For sacral tumors, complication rates of up to 100% have been reported and complication-related death ranged from 0% to 27%. Mobile spine tumor complication rates varied from 13% to 73.7% and complication-related death ranged from 0% to 7.7%. Seven articles examining HRQOL for this patient population were identified. The limited literature showed comparable patient HRQOL profiles to those with benign conditions such as degenerative disc disease. CONCLUSION Respecting oncologic principles for primary spinal tumors are correlated with high adverse event rates. We recommend that primary spinal tumor surgeries be performed in experienced centers with multidisciplinary support teams and that prospective adverse event collection be promoted (strong recommendation/very low certainty of the evidence). Oncologic resection of primary tumors of the spine is associated with HRQOL that more closely approximates normative values with increasing duration of follow-up, but decreases with disease recurrence. We recommend primary spinal tumor surgery be performed with a curative intent whenever possible, even at the expense of greater initial morbidity to optimize long-term HRQOL (strong recommendation/very low certainty of the evidence). LEVEL OF EVIDENCE N/A.
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Qian J, Bao Z, Zou J, Yang H. Effect of pedicle fixation combined with (125)I seed implantation for metastatic thoracolumbar tumors. J Pain Res 2016; 9:271-8. [PMID: 27274307 PMCID: PMC4869845 DOI: 10.2147/jpr.s105284] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Purpose The aim of this study was to investigate the clinical efficacy of pedicle fixation combined with 125I brachytherapy in treating metastatic thoracolumbar tumors. Patients and methods A retrospective analysis of the clinical data of seven metastatic thoracolumbar tumor patients who received pedicle fixation combined with radioactive 125I seed implantation brachytherapy in our department between January 2009 and December 2013 was performed. The visual analog scale (VAS) for pain and the Karnofsky performance status (KPS) score before the operation and 1, 6, and 12 months after the operation were observed and recorded. The changes in the scores at each time point were compared. Results All the patients underwent a successful operation, without any complications during their hospitalization. All the patients received postoperative follow-up, and the duration of follow-up was 15–50 months, with an average of 32.2 months. One pancreatic cancer patient died of liver failure and hypoproteinemia 28 months post surgery. The VAS scores of patients before the operation and 1, 6, and 12 months after the operation were 7.43±0.98, 2.71±0.49, 3.00±0.82, and 4.29±0.98, respectively; the KPS scores were 52.9±9.5, 84.3±5.3, 75.7±5.3, and 72.9±4.9, respectively. These results suggest that the VAS score at each time point was significantly decreased compared with that before the operation, while the KPS score was significantly increased compared with that before the operation. Both differences had statistical significance (P<0.05). Conclusion As a therapy for advanced malignant tumors with thoracolumbar metastasis, pedicle fixation combined with 125I brachytherapy can effectively relieve short-term pain and improve patient’s quality of life.
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Affiliation(s)
- Jiale Qian
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Zhaohua Bao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Jun Zou
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
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de Oliveira MF, Rotta JM, Botelho RV. Is there a relationship between spinal instability in neoplastic disease and Tokuhashi scoring system? Neurosurg Rev 2016; 39:519-24. [PMID: 26860530 DOI: 10.1007/s10143-016-0706-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 01/27/2016] [Indexed: 11/30/2022]
Abstract
Spinal instability neoplastic score (SINS) classification evaluates spinal stability by adding together six radiographic and clinical components. The objective of this study was to verify the association between SINS and Tokuhashi scoring system (TSS) score. Fifty-eight patients with vertebral metastases were admitted from 2010 to 2014 at Hospital do Servidor Público Estadual de São Paulo. They were evaluated according to their SINS and Tokuhashi SS score. Fourteen patients (24.13 %) scored from 0 to 6 points (stable spine), 37 (63.79 %) scored from 7 to 12 (potentially unstable), and 7 (12.06 %) scored from 13 to 18 (unstable). In stable spine patients according to SINS, the mean TSS score was 9.2. In potentially unstable spine patients, the mean TSS score was 8.24. In unstable spine patients, mean TSS score was 6.28. There was a statistically significant difference of the TSS score between stable and unstable patients. After evaluating TSS score in each patient, the worse the SINS, the worse was also the TSS score.
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Affiliation(s)
- Matheus Fernandes de Oliveira
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Av. Loefgren, 700, apto 103, Vila Clementino, Indianópolis, São Paulo, 04040-000, Brazil.
| | - Jose Marcus Rotta
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Av. Loefgren, 700, apto 103, Vila Clementino, Indianópolis, São Paulo, 04040-000, Brazil
| | - Ricardo Vieira Botelho
- Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo, IAMSPE, Av. Loefgren, 700, apto 103, Vila Clementino, Indianópolis, São Paulo, 04040-000, Brazil
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Fehlings MG, Nater A, Tetreault L, Kopjar B, Arnold P, Dekutoski M, Finkelstein J, Fisher C, France J, Gokaslan Z, Massicotte E, Rhines L, Rose P, Sahgal A, Schuster J, Vaccaro A. Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study. J Clin Oncol 2015; 34:268-76. [PMID: 26598751 DOI: 10.1200/jco.2015.61.9338] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management. PATIENTS AND METHODS One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively. RESULTS Median survival time was 7.7 months. The 30-day and 12-month mortality rates were 9% and 62%, respectively. There was improvement at 6 months postoperatively for ambulatory status (McNemar test, P < .001), lower extremity and total motor scores (Wilcoxon signed rank test, P < .001), and at 6 weeks and 3, 6, and 12 months for Oswestry Disability Index, EQ-5D, and pain interference (paired t test, P < .013). Moreover, at 3 months after surgery, the ASIA impairment scale grade was improved (Stuart-Maxwell test P = .004). SF-36 scores improved postoperatively in six of eight scales. The incidence of wound complications was 10% and 2 patients required a second surgery (screw malposition and epidural hematoma). CONCLUSION Surgical intervention, as an adjunct to radiation and chemotherapy, provides immediate and sustained improvement in pain, neurologic, functional, and HRQoL outcomes, with acceptable risks in patients with a focal symptomatic MESCC lesion who have at least a 3 month survival prognosis.
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Affiliation(s)
- Michael G Fehlings
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA.
| | - Anick Nater
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Lindsay Tetreault
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Branko Kopjar
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Paul Arnold
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Mark Dekutoski
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Joel Finkelstein
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Charles Fisher
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - John France
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Ziya Gokaslan
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Eric Massicotte
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Laurence Rhines
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Peter Rose
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Arjun Sahgal
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - James Schuster
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
| | - Alexander Vaccaro
- Michael G. Fehlings, Anick Nater, Lindsay Tetreault, and Eric Massicotte, University of Toronto; Joel Finkelstein and Arjun Sahgal, Sunnybrook Health Sciences Center, Toronto, Ontario; Charles Fisher, University of British Columbia and Vancouver Coastal Health, Vancouver, British Columbia, Canada; Branko Kopjar, University of Washington, Seattle, WA; Paul Arnold, University of Kansas, Kansas City, KS; Mark Dekutoski, The CORE Institute, Sun City West, AZ; John France, West Virginia University, Morgantown, WV; Ziya Gokaslan, Johns Hopkins University School of Medicine, Baltimore, MD; Laurence Rhines, MD Anderson Cancer Center, Houston, TX; Peter Rose, Mayo Clinic, Rochester, MN; James Schuster, University of Pennsylvania; and Alexander Vaccaro, Thomas Jefferson University, Philadelphia, PA
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Lee SH, Grant R, Kennedy C, Kilbride L. Positioning and spinal bracing for pain relief in metastatic spinal cord compression in adults. Cochrane Database Syst Rev 2015; 2015:CD007609. [PMID: 26400848 PMCID: PMC7199117 DOI: 10.1002/14651858.cd007609.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 3 (Lee 2012) on patient positioning (mobilisation) and bracing for pain relief and spinal stability in adults with metastatic spinal cord compression.Many patients with metastatic spinal cord compression (MSCC) have spinal instability, but their clinician has determined that due to their advanced disease they are unsuitable for surgical internal fixation. Mobilising may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (whether a patient should be managed with bed rest or allowed to mobilise) and whether spinal bracing is helpful, is contradictory. OBJECTIVES To investigate the correct positioning and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. SEARCH METHODS For this update, we searched for relevant studies from February 2012 to 31 March 2015. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In Process, EMBASE, AMED, CINAHL, TRIP, SIGN, NICE, UK Clinical Research Network, National Guideline Clearinghouse and PEDro database. We also searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov, UK Clinical Trials Gateway (UKCTG), WHO International Clinical Trials Registry Platform (ICTRP) and Australia New Zealand Clinical Trials Registry (ANZCTR).For the original version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse, and PEDro database, in February 2012. SELECTION CRITERIA We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning (mobilisation) and bracing. DATA COLLECTION AND ANALYSIS Two review authors independently assessed each possible study for inclusion and quality. MAIN RESULTS For the original version of the review, we screened 1611 potentially relevant studies. No studies met the inclusion criteria. Many papers identified the importance of mobilisation, but no RCTs of bed rest versus mobilisation have been undertaken. We identified no RCTs of bracing in MSCC.For this update, we identified 347 potential titles. We screened 300 titles and abstracts after removal of duplicates. We did not identify any additional studies for inclusion. AUTHORS' CONCLUSIONS Since publication of the original version of this review, no new studies were found and our conclusions remain unchanged.There is a lack of evidence-based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.
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Affiliation(s)
- Siew Hwa Lee
- University of LimerickDepartment of Nursing and Midwifery, Faculty of Education and Health SciencesHealth Sciences BuildingRoom HS3‐029LimerickIreland
| | - Robin Grant
- Western General HospitalEdinburgh Centre for Neuro‐Oncology (ECNO)Crewe RoadEdinburghScotlandUKEH4 2XU
| | - Catriona Kennedy
- University of LimerickDepartment of Nursing and Midwifery, Faculty of Education and Health SciencesHealth Sciences BuildingRoom HS3‐029LimerickIreland
| | - Lynn Kilbride
- Glasgow Caledonian UniversityNursing and Community HealthGlasgowUK
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George R, Sundararaj JJ, Govindaraj R, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev 2015; 2015:CD006716. [PMID: 26337716 PMCID: PMC6513178 DOI: 10.1002/14651858.cd006716.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Metastatic extradural spinal cord compression (MESCC) is treated with radiotherapy, corticosteroids, and surgery, but there is uncertainty regarding their comparative effects. This is an updated version of the original Cochrane review published in theCochrane Database of Systematic Reviews (Issue 4, 2008). OBJECTIVES To determine the efficacy and safety of radiotherapy, surgery and corticosteroids in MESCC. SEARCH METHODS In March 2015, we updated previous searches (July 2008 and December 2013) of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, CANCERLIT, clinical trials registries, conference proceedings, and references, without language restrictions. We also contacted experts for relevant published, unpublished and ongoing trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC. DATA COLLECTION AND ANALYSIS Three authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. Where possible, we pooled relative risks with their 95% confidence intervals, using a random effects model if heterogeneity was significant. We assessed overall evidence-quality using the GRADE approach. MAIN RESULTS This update includes seven trials involving 876 (723 evaluable) adult participants (19 to 87 years) in high-income countries. Most were free of the risk of bias. Different radiotherapy doses and schedulesTwo equivalence trials in people with MESCC and a poor prognosis evaluated different radiotherapy doses and schedules. In one, a single dose (8 Gray (Gy)) of radiotherapy (RT) was as effective as short-course RT (16 Gy in two fractions over one week) in enhancing ambulation in the short term (65% versus 69%; risk ratio (RR) was 0.93, (95% confidence interval (CI) 0.82 to 1.04); 303 participants; moderate quality evidence). The regimens were also equally effective in reducing analgesic and narcotic use (34% versus 40%; RR 0.85, 95% CI 0.62 to 1.16; 271 participants), and in maintaining urinary continence (90% versus 87%; RR 1.03, 95% CI 0.96 to 1.1; 303 participants) in the short term (moderate quality evidence). In the other trial, split-course RT (30 Gy in eight fractions over two weeks) was no different from short-course RT in enhancing ambulation (70% versus 68%; RR 1.02, 95% CI 0.9 to 1.15; 276 participants); reducing analgesic and narcotic use (49% versus 38%; RR 1.27, 95% CI 0.96 to 1.67; 262 participants); and in maintaining urinary continence (87% versus 90%; RR 0.97, 0.93 to 1.02; 275 participants) in the short term (moderate quality evidence). Median survival was similar with the three RT regimens (four months). Local tumour recurrence may be more common with single-dose compared to short-course RT (6% versus 3%; RR 2.21, 95% CI 0.69 to 7.01; 303 participants) and with short-course compared to split-course RT (4% versus 0%; RR 0.1, 95% CI 0.01 to 1.72; 276 participants), but these differences were not statistically significant (low quality evidence). Gastrointestinal adverse effects were infrequent with the three RT regimens (moderate quality evidence), and serious adverse events or post-radiotherapy myelopathy were not noted.We did not find trials comparing radiotherapy schedules in people with MESCC and a good prognosis. Surgery plus radiotherapy compared to radiotherapyLaminectomy plus RT offered no advantage over RT in one small trial with 29 participants (very low quality evidence). In another trial that was stopped early for apparent benefit, decompressive surgery plus RT resulted in better ambulatory rates (84% versus 57%; RR 1.48, 95% CI 1.16 to 1.90; 101 participants, low quality evidence). Narcotic use may also be lower, and bladder control may also be maintained longer than with than RT in selected patients (low quality evidence). Median survival was longer after surgery (126 days versus 100 days), but the proportions surviving at one month (94% versus 86%; RR 1.09, 95% CI 0.96 to 1.24; 101 participants) did not differ significantly (low quality evidence). Serious adverse events were not noted. Significant benefits with surgery occurred only in people younger than 65 years. High dose corticosteroids compared to moderate dose or no corticosteroidsData from three small trials suggest that high-dose steroids may not differ from moderate-dose or no corticosteroids in enhancing ambulation (60% versus 55%; RR 1.08, 95% CI 0.81 to 1.45; 3 RCTs, 105 participants); survival over two years (11% versus 10%; RR 1.11, 95% CI 0.24 to 5.05; 1 RCT, 57 participants); pain reduction (78% versus 91%; RR 0.86, 95% CI 0.62 to 1.20; 1 RCT, 25 participants); or urinary continence (63% versus 53%; RR 1.18, 95% CI 0.66 to 2.13; 1 RCT, 34 participants; low quality evidence). Serious adverse effects were more frequent with high-dose corticosteroids (17% versus 0%; RR 8.02, 95% CI 1.03 to 62.37; 2 RCTs, 77 participants; moderate quality evidence).None of the trials reported satisfaction with care or quality of life in participants. AUTHORS' CONCLUSIONS Based on current evidence, ambulant adults with MESCC with stable spines and predicted survival of less than six months will probably benefit as much from one dose of radiation (8 Gy) as from two doses (16 Gy) or eight doses (30 Gy). We are unsure if a single dose is as effective as two or more doses in preventing local tumour recurrence. Laminectomy preceding radiotherapy may offer no benefits over radiotherapy alone. Decompressive surgery followed by radiotherapy may benefit ambulant and non-ambulant adults younger than 65 years of age, with poor prognostic factors for radiotherapy, a single area of compression, paraplegia for less than 48 hours, and a predicted survival of more than six months. We are uncertain whether high doses of corticosteroids offer any benefits over moderate doses or indeed no corticosteroids; but high-dose steroids probably significantly increases the risk of serious adverse effects. Early detection; and treatment based on neurological status, age and estimated survival, are crucial with all treatment modalities. Most of the evidence was of low quality. High-quality evidence from more trials is needed to clarify current uncertainties, and some studies are in progress.
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Affiliation(s)
- Reena George
- Christian Medical CollegePalliative Care UnitVelloreTamil NaduIndia632004
| | | | - Ramkumar Govindaraj
- Royal Adelaide HospitalDepartment of Radiation OncologyNorth TerraceAdelaideSAAustralia5000
| | - Ari G Chacko
- Christian Medical CollegeNeurosciencesVelloreTamil NaduIndia632002
| | - Prathap Tharyan
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
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Comparison of the Therapeutic Efficacy of Surgery with or without Adjuvant Radiotherapy versus Radiotherapy Alone for Metastatic Spinal Cord Compression: A Meta-Analysis. World Neurosurg 2015; 83:1066-73. [DOI: 10.1016/j.wneu.2014.12.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 12/15/2014] [Indexed: 11/20/2022]
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Abordaje anterior y anterolateral en el tratamiento de la compresión medular metastásica a nivel torácico y lumbar. Neurocirugia (Astur) 2015; 26:126-36. [DOI: 10.1016/j.neucir.2014.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 08/15/2014] [Accepted: 11/01/2014] [Indexed: 11/30/2022]
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Oliveira MFD, Rotta JM, Botelho RV. Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:330-5. [DOI: 10.1590/0004-282x20150003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/11/2014] [Indexed: 11/22/2022]
Abstract
Spine is the most common site for skeletal metastasis in patients with malignancy. Vertebral involvement quantification, neurological status, general health status and primary tumor histology are factors to set surgical planning and therapeutic targets. We evaluated the impact of general clinical and neurological status, histologic type and surgery in survival. Method : The study sample consisted of consecutive patients admitted from July 2010 to January 2013 for treatment. Results : Sixty eight patients were evaluated. 23 were female and 45 were male. Main primary neoplasic sites were: breast, prostate, lung/pleura and linfoproliferative. Thirty three out of 68 received surgical treatment, 2 received percutaneous biopsy and 33 had nonsurgical treatment. Survival : Log Rank curves revealed no statistical significant difference according to histological type, surgical approach and Frankel Score. Karnofsky Score was statistically different. Conclusion : Histological type and clinical status were statistically associated with life expectancy in vertebral metastatic disease.
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Park HY, Lee SH, Park SJ, Kim ES, Lee CS, Eoh W. Minimally invasive option using percutaneous pedicle screw for instability of metastasis involving thoracolumbar and lumbar spine : a case series in a single center. J Korean Neurosurg Soc 2015; 57:100-7. [PMID: 25733990 PMCID: PMC4345186 DOI: 10.3340/jkns.2015.57.2.100] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/21/2014] [Accepted: 08/13/2014] [Indexed: 11/27/2022] Open
Abstract
Objective To report a minimally invasive treatment option using percutaneous pedicle screw fixation with adjuvant treatment for metastatic thoraco-lumbar and lumbar spinal tumors. Methods This is a retrospective study of charts of patients with spinal metastases. All were older than 18 years of age and were considered to have more than 3 months of life expectancy. The patients had single or two level lesions, and compression fracture or impending fracture. Exclusion criterion was metastasis showing severe epidural compression with definite neurological symptoms. Usually spinal segments from one level above to below pathology were stabilized. Visual analog scale (VAS) score for pain assessment and Frankel scale for neurological deficit were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG). Results Twelve patients (nine men, three women; median age 54.29 years) underwent surgery. All patients presented with back pain with/without radicular pain. There were no early complications and perioperative mortalities. Following surgery, a significant difference between average pre- and post-operative VAS scores was found (p=0.003). Overall, 91.8% of patients (11/12) experienced improvement in their ECOG score post-operatively. The mean ambulation time was 196.9 days [95% confidence interval (CI), 86.2-307.6 days; median, 97 days]. During follow-up, nine patients died and the mean overall survival time in enrolled twelve patients was 249.9 days (95% CI, 145.3-354.4 days; median, 176 days). Conclusion Minimally invasive treatment using percutaneous pedicle screw fixation with adjuvant treatment is a good alternative treatment option for potential instability of the thoraco-lumbar and lumbar spinal metastasis.
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Affiliation(s)
- Ho-Young Park
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se-Jun Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong-Suh Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Whan Eoh
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dea N, Versteeg A, Fisher C, Kelly A, Hartig D, Boyd M, Paquette S, Kwon BK, Dvorak M, Street J. Adverse events in emergency oncological spine surgery: a prospective analysis. J Neurosurg Spine 2014; 21:698-703. [DOI: 10.3171/2014.7.spine131007] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Most descriptions of spine surgery morbidity and mortality in the literature are retrospective. Emerging prospective analyses of adverse events (AEs) demonstrate significantly higher rates, suggesting underreporting in retrospective and prospective studies that do not include AEs as a targeted outcome. Emergency oncological spine surgeries are generally palliative to reduce pain and improve patients' neurology and health-related quality of life. In individuals with limited life expectancy, AEs can have catastrophic implications; therefore, an accurate AE incidence must be considered in the surgical decision-making process. The purpose of this study was to determine the true incidence of AEs associated with emergency oncological spine surgery.
Methods
The authors carried out a prospective cohort study in a quaternary care referral center that included consecutive patients admitted between January 1, 2009, and December 31, 2012. Inclusion criteria were all patients undergoing emergency surgery for metastatic spine disease. AE data were reported and collected on standardized AE forms (Spine AdVerse Events Severity System, version 2 [SAVES V2] forms) at weekly dedicated morbidity and mortality rounds attended by attending surgeons, residents, fellows, and nursing staff.
Results
A total of 101 patients (50 males, 51 females) met the inclusion criteria and had complete data. Seventysix patients (76.2%) had at least 1 AE, and 11 patients (10.9%) died during their admission. Intraoperative surgical AEs were observed in 32% of patients (9.9% incidental durotomy, 16.8% blood loss > 2 L). Transient neurological deterioration occurred in 6 patients (5.9%). Infectious complications in this patient population were significant (surgical site 6%, other 50.5%). Delirium complicated the postoperative period in 20.8% of cases.
Conclusions
When evaluated in a rigorous prospective manner, metastatic spine surgery is associated with a higher morbidity rate than previously reported. This AE incidence must be considered by the patient, oncologist, and surgeon to determine appropriate management and preventative strategies to reduce AEs in this fragile patient population.
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Affiliation(s)
- Nicolas Dea
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Anne Versteeg
- 2Department of Orthopaedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Charles Fisher
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Adrienne Kelly
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Dennis Hartig
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Michael Boyd
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Scott Paquette
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Brian K. Kwon
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - Marcel Dvorak
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
| | - John Street
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and
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Cost-effectiveness of surgery in the management of metastatic epidural spinal cord compression: a systematic review. Spine (Phila Pa 1976) 2014; 39:S99-S105. [PMID: 25077913 DOI: 10.1097/brs.0000000000000525] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To perform an evidence-based synthesis of the literature to examine the cost-effectiveness of surgery in the management of metastatic epidural spinal cord compression (MESCC). SUMMARY OF BACKGROUND DATA Between 2.5% and 10% of patients with cancer develop symptomatic MESCC, which leads to significant morbidity, and a reduction in quality and length of life. Although surgery is being increasingly used in the management of MESCC, it is unclear whether this modality is cost-effective, given the relatively limited lifespan of these patients. METHODS Numerous databases were searched to identify full economic studies based on key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Two independent reviewers examined the full text of the articles meeting inclusion criteria to obtain the final cohort of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers. RESULTS The search strategy yielded 38 potentially relevant citations, 2 of which met the inclusion criteria. One was a cost-utility study and the other was a cost-effectiveness study, and both used clinical data from the same randomized controlled trial. Both studies found surgery plus radiotherapy to be not only more expensive but also more effective than radiotherapy alone in the management of patients with MESCC. CONCLUSION There is evidence from 2 high-quality studies that surgery plus radiotherapy is costlier but clinically more effective than radiotherapy alone for the management of MESCC. Of note, cost-effectiveness data for the role of spinal stabilization in the management of oncological spinal instability are lacking. This is a key knowledge gap that represents an opportunity for future research.
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Moliterno J, Veselis CA, Hershey MA, Lis E, Laufer I, Bilsky MH. Improvement in pain after lumbar surgery in cancer patients with mechanical radiculopathy. Spine J 2014; 14:2434-9. [PMID: 24614256 DOI: 10.1016/j.spinee.2014.03.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/24/2014] [Accepted: 03/01/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar metastases can result in spinal instability and mechanical radiculopathy, characterized by radicular pain produced by axial loading. This pain pattern represents a definitive symptom of neoplastic instability and may serve as a reliable indication for surgical stabilization. PURPOSE We examined the results of surgical decompression and fixation in the treatment of mechanical radiculopathy. STUDY DESIGN/SETTING A retrospective clinical study. PATIENT SAMPLE An internally maintained spine neurosurgery database was queried between February 2002 and April 2010. Patients were identified and deemed eligible for inclusion in this study based on the presence of all the following: metastatic tumor, lumbar surgery, and lumbar radiculopathy. OUTCOME MEASURES Visual analog scale (VAS) of pain and Eastern Cooperative Oncology Group (ECOG) status. METHODS The Memorial Sloan-Kettering Cancer Center Department of Neurosurgery operative database was queried over an 8-year period to identify all patients with spinal metastases who underwent lumbar surgery. Only patients whose operative indication included mechanical radiculopathy were included. Pre- and postoperative pain was assessed with the VAS of pain, whereas pre- and postoperative performance status was evaluated using the ECOG. RESULTS Fifty-five patients were included in the cohort. L2 and L3 were the most common levels involved, and most patients underwent multilevel posterior decompression and instrumented fusion. After surgery, 98% of patients reported pain relief. A significant difference between average pre- and postoperative pain scores was found (p<.01). Overall, 41.5% of patients experienced improvement in their ECOG score postoperatively. CONCLUSIONS Mechanical radiculopathy in patients with spinal metastases represents a highly reliable surgical indication. Spinal decompression and fixation is an effective treatment for pain palliation in this patient population.
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Affiliation(s)
- Jennifer Moliterno
- Department of Neurosurgery, Yale School of Medicine, South Frontage Road and Park Street, New Haven, CT 06510, USA
| | - Clinton A Veselis
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Michael A Hershey
- Department of Anesthesiology, Columbia University, 622 West 168th Street, New York, NY 10032, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Gerszten PC. Spine Metastases: From Radiotherapy, Surgery, to Radiosurgery. Neurosurgery 2014; 61 Suppl 1:16-25. [DOI: 10.1227/neu.0000000000000375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Peter C. Gerszten
- Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Kasliwal MK, Tan LA, O'Toole JE. Intradural tumor recurrence after resection of extradural metastasis: a rare but potential complication of intraoperative durotomy. J Neurosurg Spine 2014; 20:734-9. [DOI: 10.3171/2014.3.spine13896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal metastases are the most common of spinal neoplasms and occur predominantly in an extradural location. Their appearance in an intradural location is uncommon and is associated with a poor prognosis. Cerebrospinal fluid dissemination accounts for a significant number of intradural spinal metastases mostly manifesting as leptomeningeal carcinomatoses or drop metastases from intracranial tumors. The occurrence of local tumor dissemination intradurally following surgery for an extradural spinal metastasis has not been reported previously. The authors describe 2 cases in which local intradural and intramedullary tumor recurrences occurred following resection of extradural metastases that were complicated by unintended durotomy. To heighten clinical awareness of this unusual form of local tumor recurrence, the authors discuss the possible etiology and clinical consequences of this entity.
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Itshayek E, Cohen JE, Yamada Y, Gokaslan Z, Polly DW, Rhines LD, Schmidt MH, Varga PP, Mahgarefteh S, Fraifeld S, Gerszten PC, Fisher CG. Timing of stereotactic radiosurgery and surgery and wound healing in patients with spinal tumors: a systematic review and expert opinions. Neurol Res 2014; 36:510-23. [DOI: 10.1179/1743132814y.0000000380] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Direct decompressive surgery followed by radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression: a meta-analysis. Spine (Phila Pa 1976) 2014; 39:E587-92. [PMID: 24503688 DOI: 10.1097/brs.0000000000000258] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A systemic review and meta-analysis. OBJECTIVE To compare the ambulatory status and survival for metastatic epidural spinal cord compression (MESCC) in patients treated with direct decompressive surgical resection (DDSR) followed by radiotherapy (RTx) with those in patients treated with RTx alone. SUMMARY OF BACKGROUND DATA Surgical techniques have remarkably evolved from decompressive laminectomy without ventral tumor excision to DDSR, which has displayed favorable outcomes since the 2000s. RTx alone has also evolved and is regarded to have accomplished outcome comparable with that of the surgery. The optimal treatment of MESCC has not been clearly defined yet. METHODS We searched MEDLINE, EMBASE, and the Cochrane library in July 2013. Comparative studies enrolled patients with similar performance, primary cancer, age, and sex at the baseline state were included. Outcome measures included ambulatory status and overall survival rate. We did a fixed-effects meta-analysis of the ambulatory status and survival in patients with MESCC compared with DDSR+RTx and RTx alone. RESULTS Five studies were used to obtain data from 238 and 1137 patients treated with DDSR+RTx and RTx alone, respectively. The DDSR+RTx group displayed substantial improvement in ambulatory status after the treatment that was superior to the improvement in the RTx-alone group (relative risk [RR], 1.43; 95% confidence interval [CI], 1.14-1.78) in a fixed-effects model and significantly lower deterioration after treatment than the RTx group (RR, 0.35; 95% CI, 0.19-0.63). The DDSR+RTx group showed significant improvement in the survival rate at 6 months post-treatment (RR, 1.21; 95% CI, 1.09-1.33). Similar findings were observed at 12 months post-treatment (RR, 1.32; 95% CI, 1.12-1.56). CONCLUSION The meta-analysis indicates that DDSR+RTx may produce better clinical improvement of ambulation status and survival than RTx alone in the treatment of MESCC. Additional prospective studies are warranted to better address this question. LEVEL OF EVIDENCE 1.
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Itshayek E, Or O, Kaplan L, Schroeder J, Barzilay Y, Rosenthal G, Shoshan Y, Fraifeld S, Cohen JE. Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older. Neurol Res 2014; 36:530-43. [DOI: 10.1179/1743132814y.0000000368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Druschel C, Disch AC, Pumberger M, Schwabe P, Melcher I, Haas NP, Schaser KD. [Solitary spinal metastases. Is aggressive surgical management justified?]. DER ORTHOPADE 2014; 42:709-24. [PMID: 23989590 DOI: 10.1007/s00132-013-2066-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Advances in oncological and surgical therapies have led to a significant increase in life expectancy of cancer patients and also prolonged survival of patients with isolated or multiple metastases. Among the skeletal manifestations the spine is the most often affected site. Using novel imaging techniques with higher resolution and use of metabolic signatures, the screening of cancer patients has improved considerably. Consequently, the diagnosis of metastases is becoming increasingly more sensitive. Therefore, but also due to more effective polychemotherapy protocols, singular or solitary metastases are more frequently observed either in the early stages or as a result of a controlled malignant tumor entity (stable disease). The questions whether a solitary metastasis really exists (illusion or reality?) and its radical oncological and surgical treatment as a circumscribed singular tumor manifestation, is really relevant for the overall prognosis, remains controversial. However, it seems evident that a biologically favorable underlying tumor biology, radical treatment of the primary tumor and a long metastasis-free interval are valid predictors of a good oncological outcome. In the presence of a solitary metastasis under these circumstances (typical example: solitary metastasis of renal cell carcinoma many years after radical tumor nephrectomy) a radical surgical procedure (en bloc spondylectomy) can significantly improve the long-term prognosis of this patient group in combination with adjuvant chemotherapy and/or radiotherapy. However, a thorough evaluation of the overall survival prognosis, a detailed and complete staging followed by a treatment consensus in the interdisciplinary tumor board has to precede any therapeutical decisions.
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Affiliation(s)
- C Druschel
- Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie, Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland
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Spencer BA, Shim JJ, Hershman DL, Zacharia BE, Lim EA, Benson MC, Neugut AI. Metastatic epidural spinal cord compression among elderly patients with advanced prostate cancer. Support Care Cancer 2014; 22:1549-55. [DOI: 10.1007/s00520-013-2112-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 12/25/2013] [Indexed: 10/25/2022]
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Teixeira WGJ, Coutinho PRDM, Marchese LD, Narazaki DK, Cristante AF, Teixeira MJ, Barros Filho TEPD, Camargo OPD. Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator. Clinics (Sao Paulo) 2013; 68:213-8. [PMID: 23525318 PMCID: PMC3584270 DOI: 10.6061/clinics/2013(02)oa15] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/19/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties. METHODS Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient. RESULTS Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases. CONCLUSIONS This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.
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Kaloostian PE, Gokaslan ZL. The Current Role of Surgery in Metastatic Spine Disease: A New Era. Ann Surg Oncol 2012; 20:1-2. [DOI: 10.1245/s10434-012-2645-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kim CH, Chung CK, Jahng TA, Kim HJ. Surgical outcome of spinal hepatocellular carcinoma metastases. Neurosurgery 2012; 68:888-96. [PMID: 21221023 DOI: 10.1227/neu.0b013e3182098c18] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Spinal hepatocellular carcinoma (HCC) metastases are increasing with improved survival of patients with HCC. However, its treatment outcome, particularly regarding functional outcome, has not been adequately investigated. OBJECTIVE To present the surgical outcome of spinal HCC metastases and demonstrate prognostic factors for survival and ambulation time. METHODS Thirty-three patients (30 males, 3 females) were retrospectively reviewed. Child-Pugh classification was used to assess hepatic function. Preoperatively, 19 patients could ambulate (group A) and 14 patients could not (group B). Preoperatively, 18 patients received conventional fractionated radiotherapy. RESULTS The spinal metastases were removed to achieve sufficient neural decompression. If destabilization developed, instrumentation and/or vertebroplasty were performed. Postoperatively, conventional radiotherapy was administered to 13 patients. Patients survived for 203 ± 31 days. Child-Pugh classification and preoperative/postoperative ambulatory ability were correlated with survival time, with Child-Pugh classification being the most significant factor (hazard ratio, 3.75; 95% confidence interval: 1.38-10.22). After the operation, ambulatory ability was maintained in all group A patients and was recovered in 4 in group B. Twenty-three patients could ambulate for 285 ± 62 days. Preoperative ambulatory status and Child-Pugh classification were correlated with a longer ambulatory period, with preoperative ambulatory status most significant (hazard ratio, 8.62; 95% confidence interval: 2.39-31.04). Patients died 81 ± 71 days after the loss of ambulatory ability, regardless of postoperative ambulatory status. CONCLUSION In spinal HCC metastasis, ambulatory status and hepatic function were significantly correlated with survival and ambulation time. Both ambulatory status and hepatic function should be considered in the selection of surgical candidates.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
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Furlan JC, Chan KKW, Sandoval GA, Lam KCK, Klinger CA, Patchell RA, Laporte A, Fehlings MG. The combined use of surgery and radiotherapy to treat patients with epidural cord compression due to metastatic disease: a cost-utility analysis. Neuro Oncol 2012; 14:631-40. [PMID: 22505658 PMCID: PMC3337309 DOI: 10.1093/neuonc/nos062] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 01/23/2012] [Indexed: 11/14/2022] Open
Abstract
Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
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Affiliation(s)
- Julio C Furlan
- Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T 2S8.
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Lee SH, Cox KM, Grant R, Kennedy C, Kilbride L. Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults. Cochrane Database Syst Rev 2012:CD007609. [PMID: 22419325 DOI: 10.1002/14651858.cd007609.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Many patients with metastatic spinal cord compression (MSCC) have spinal instability but are determined, by their clinician, to be unsuitable for surgical internal fixation due to their advanced disease. Mobilisation may be hazardous in the presence of spinal instability as further vertebral collapse can occur. Current guidance on positioning (or mobilisation) and spinal bracing is contradictory. OBJECTIVES To investigate the correct positioning (or mobilisation) and examine the effects of spinal bracing to relieve pain or to prevent further vertebral collapse in patients with MSCC. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, NICE, SIGN, AMED, TRIP, National Guideline Clearinghouse and PEDro database were searched; the last search was run in February 2012. SELECTION CRITERIA We selected randomised controlled trials (RCTs) of adults with MSCC of interventions on positioning or mobilisation and bracing. DATA COLLECTION AND ANALYSIS Two review authors independently assessed each possible study for inclusion and quality. MAIN RESULTS One thousand, six hundred and eleven potentially relevant studies were screened. No studies met the inclusion criteria. Many papers identified the importance of mobilisation but no RCTs have been undertaken. No RCTs of bracing in MSCC were identified. AUTHORS' CONCLUSIONS There is lack of evidence based guidance around how to correctly position and when to mobilise patients with MSCC or if spinal bracing is an effective technique for reducing pain or improving quality of life. RCTs are required in this important area.
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Affiliation(s)
- Siew Hwa Lee
- School of Nursing, Midwifery and Social Care, Faculty of Health, Life & Social Sciences, Edinburgh Napier University, Edinburgh,UK
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Dasenbrock HH, Pradilla G, Witham TF, Gokaslan ZL, Bydon A. The Impact of Weekend Hospital Admission on the Timing of Intervention and Outcomes After Surgery for Spinal Metastases. Neurosurgery 2012; 70:586-93. [DOI: 10.1227/neu.0b013e318232d1ee] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Kim CH, Chung CK, Jahng TA, Kim HJ. Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis. Spine J 2011; 11:1015-23. [PMID: 22000724 DOI: 10.1016/j.spinee.2011.09.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/19/2011] [Accepted: 09/07/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Improving the surgical outcome of nonambulatory patients with metastatic epidural spinal compression has been of great interest lately. Although there have been many reports regarding the surgical outcome of spinal metastasis, the surgical outcome in terms of the probability of operative success for nonambulatory patients has not been thoroughly described. If the probability of ambulatory recovery is known, the optimal surgical indications can be determined and implemented. PURPOSE To predict the surgical outcome and probability of ambulatory resumption for nonambulatory patients with spinal metastasis. STUDY DESIGN Retrospective analysis. PATIENT SAMPLE The surgical outcomes of patients who could not ambulate independently because of spinal metastasis from 1987 to 2010 were analyzed. OUTCOME MEASURES The primary end point was postoperative ambulatory status. The secondary end point was survival time. METHODS Fifty-seven patients who could not ambulate independently at the time of surgery were included in the study. We defined "independent ambulation" as a better functional status than Nurick Grade 3, which is defined as "difficulty in walking which was not so severe as to require someone's help to walk." Preoperatively, functional status was Nurick Grade 4 in 21 patients and Grade 5 in 36 patients. Weakness developed 10.5 ± 11.9 days (median, 7.0; range, 1-80) before the operation and steadily worsened. Patients were unable to walk starting from 3.6 ± 4.9 days (median, 1.8; range, 0.5-23) before the operation. The spinal metastases were circumferentially decompressed. RESULTS Postoperatively, 39 patients (68%) could walk. Complications occurred in 26% (15/57) of the patients, and the major complication rate was 12% (7/57). The mortality rate was 5% (3/57). The patient survival time was 287 ± 51 days (median, 128) after the operation. Postoperative ambulatory status (yes vs. no, p < .01) and occurrence of major complication (yes vs. no, p < .01) affected survival time. Overall, patients could walk for 193±41 days (median, 114) postoperatively. Motor grade (grade ≥ 4/5 vs. <4/5, p < .01) and the occurrence of a major complication (yes vs. no, p < .01) were significant factors for resumption of ambulation. The rate of ambulation resumption was 95% (20/21) in patients with a motor grade of 4 of 5, whereas it was 53% (19/36) in patients with a motor grade less than 4 of 5 (p < .01). CONCLUSIONS The survival time of nonambulatory patients was dependent on ambulation recovery. About 95% of the nonambulatory patients could walk after surgery, when the operation was done in a timely manner with good remaining motor function. However, given the short life expectancy and the considerable surgical complication rate, surgery should only be prudently recommended to patients with optimal indications.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, South Korea
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Tomecek FJ. Commentary: Surgery for nonambulatory patients with epidural spinal metastasis: is it evidence based and cost effective? Spine J 2011; 11:1024-6. [PMID: 22122834 DOI: 10.1016/j.spinee.2011.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 10/21/2011] [Indexed: 02/03/2023]
Abstract
Commentary on: Kim CH, Chung CK, Jahng T-A, Kim HJ. Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis. Spine J 2011; 11:1015-23 (in this issue).
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Affiliation(s)
- Frank J Tomecek
- Oklahoma Spine and Brain Institute, 6802 S. Olympia Ave., Suite 300, Tulsa, OK 74132, USA
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Jennelle RLS, Vijayakumar V, Vijayakumar S. A Systematic and Evidence-Based Approach to the Management of Vertebral Metastasis. ISRN SURGERY 2011; 2011:719715. [PMID: 22084772 PMCID: PMC3200210 DOI: 10.5402/2011/719715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/21/2011] [Indexed: 11/23/2022]
Abstract
Diagnosis and management of vertebral metastasis requires a systematic approach to patient identification as well as selection of appropriate therapy. Rapid identification and prompt intervention in the treatment of malignant epidural spinal cord compression (MESCC) is key to maintaining quality of life. This paper provides a series of tools as well as guidance in selecting effective and evidence-based therapy individualized to the specific patient.
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Affiliation(s)
- Richard L. S. Jennelle
- Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
| | - Vani Vijayakumar
- Department of Nuclear Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
| | - Srinivasan Vijayakumar
- Department of Radiation Oncology, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216, USA
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Fourney DR, Frangou EM, Ryken TC, Dipaola CP, Shaffrey CI, Berven SH, Bilsky MH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fisher CG. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011; 29:3072-7. [PMID: 21709187 DOI: 10.1200/jco.2010.34.3897] [Citation(s) in RCA: 339] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS). METHODS Clinical and radiographic data from 30 patients with spinal tumors were classified as stable, potentially unstable, and unstable by members of the Spine Oncology Study Group. The median category for each patient case (consensus opinion) was used as the gold standard for predictive validity testing. On two occasions at least 6 weeks apart, each rater also scored each patient using SINS. Each total score was converted into a three-category data field, with 0 to 6 as stable, 7 to 12 as potentially unstable, and 13 to 18 as unstable. RESULTS The κ statistics for interobserver reliability were 0.790, 0.841, 0.244, 0.456, 0.462, and 0.492 for the fields of location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement, respectively. The κ statistics for intraobserver reliability were 0.806, 0.859, 0.528, 0.614, 0.590, and 0.662 for the same respective fields. Intraclass correlation coefficients for inter- and intraobserver reliability of total SINS score were 0.846 (95% CI, 0.773 to 0.911) and 0.886 (95% CI, 0.868 to 0.902), respectively. The κ statistic for predictive validity was 0.712 (95% CI, 0.676 to 0.766). CONCLUSION SINS demonstrated near-perfect inter- and intraobserver reliability in determining three clinically relevant categories of stability. The sensitivity and specificity of SINS for potentially unstable or unstable lesions were 95.7% and 79.5%, respectively.
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Affiliation(s)
- Daryl R Fourney
- University of Saskatchewan, Royal University Hospital, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada.
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