Epidemiology of spinal metastases, metastatic epidural spinal cord compression and pathologic vertebral compression fractures in patients with solid tumors: A systematic review

Machine Learning in Spine Oncology: A Narrative Review

STUDY DESIGN

Narrative Review.

OBJECTIVE

Machine learning (ML) is one of the latest advancements in artificial intelligence used in medicine and surgery with the potential to significantly impact the way physicians diagnose, prognose, and treat spine tumors. In the realm of spine oncology, ML is utilized to analyze and interpret medical imaging and classify tumors with incredible accuracy. The authors present a narrative review that specifically addresses the use of machine learning in spine oncology.

METHODS

This study was conducted in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) methodology. A systematic review of the literature in the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases since inception was performed to present all clinical studies with the search terms '[[Machine Learning] OR [Artificial Intelligence]] AND [[Spine Oncology] OR [Spine Cancer]]'. Data included studies that were extracted and included algorithms, training and test size, outcomes reported. Studies were separated based on the type of tumor investigated using the machine learning algorithms into primary, metastatic, both, and intradural. A minimum of 2 independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

RESULTS

Forty-five studies met inclusion criteria out of 480 references screened from the initial search results. Studies were grouped by metastatic, primary, and intradural tumors. The majority of ML studies relevant to spine oncology focused on utilizing a mixture of clinical and imaging features to risk stratify mortality and frailty. Overall, these studies showed that ML is a helpful tool in tumor detection, differentiation, segmentation, predicting survival, predicting readmission rates of patients with either primary, metastatic, or intradural spine tumors.

CONCLUSION

Specialized neural networks and deep learning algorithms have shown to be highly effective at predicting malignant probability and aid in diagnosis. ML algorithms can predict the risk of tumor recurrence or progression based on imaging and clinical features. Additionally, ML can optimize treatment planning, such as predicting radiotherapy dose distribution to the tumor and surrounding normal tissue or in surgical resection planning. It has the potential to significantly enhance the accuracy and efficiency of health care delivery, leading to improved patient outcomes.

Assessing a revised-risk analysis index for morbidity and mortality after spine surgery for metastatic spinal tumors

BACKGROUND

Risk Analysis Index (RAI) has been increasingly used to assess surgical frailty in various procedures, but its effectiveness in predicting mortality or in-patient hospital outcomes for spine surgery in metastatic disease remains unclear. The aim of this study was to compare the predictive values of the revised RAI (RAI-rev), the modified frailty index-5 (mFI-5), and advanced age for extended length of stay, 30-day readmission, complications, and mortality among patients undergoing spine surgery for metastatic spinal tumors.

METHODS

A retrospective cohort study was performed using the 2012-2022 ACS NSQIP database to identify adult patients who underwent spinal surgery for metastatic spinal pathologies. Using receiver operating characteristic (ROC) and multivariable analyses, we compared the discriminative thresholds and independent associations of RAI-rev, mFI-5, and greater patient age with extended length of stay (LOS), 30-day complications, hospital readmission, and mortality.

RESULTS

A total of 1,796 patients were identified, of which 1,116 (62.1%) were male and 1,008 (70.7%) were non-Hispanic White. RAI-rev identified 1,291 (71.9%) frail and 208 (11.6%) very frail patients, while mFI-5 identified 272 (15.1%) frail and 49 (2.7%) very frail patients. In the ROC analysis for extended LOS, both RAI-rev and mFI-5 showed modest predictive capabilities with area under the curve (AUC) values of 0.5477 and 0.5329, respectively, and no significant difference in their predictive abilities (p = 0.446). When compared to age, RAI-rev demonstrated superior prediction (p = 0.015). With respect to predicting 30-day readmission, no significant difference was observed between RAI-rev and mFI-5 (AUC 0.5394 l respectively, p = 0.354). However, RAI-rev outperformed age (p = 0.001). When assessing the risk of 30-day complications, RAI-rev significantly outperformed mFI-5 (AUC: 0.6016 and 0.5542 respectively, p = 0.022) but not age. Notably, RAI-rev demonstrated superior ability for predicting 30-day mortality compared to mFI-5 and age (AUC: 0.6541, 0.5652, and 0.5515 respectively, p < 0.001). Multivariate analysis revealed RAI-rev as a significant predictor of extended LOS [aOR: 1.96, 95% CI: 1.13-3.38, p = 0.016] and 30-day mortality [aOR: 5.27, 95% CI: 1.73-16.06, p = 0.003] for very frail patients. Similarly, the RAI-rev significantly predicted 30-day complications for frail [aOR: 2.63, 95% CI: 1.21-5.72, p = 0.015] and very frail [aOR: 3.69, 95% CI: 1.60-8.51, p = 0.002] patients. However, the RAI did not significantly predict 30-day readmission [Very Frail aOR: 1.52, 95% CI: 0.75-3.07, p = 0.245; Frail aOR: 1.46, 95% CI: 0.79-2.68, p = 0.225].

CONCLUSION

Our study demonstrates the utility of RAI-rev in predicting morbidity and mortality in patients undergoing spine surgery for metastatic spinal pathologies. Particularly, the superiority that RAI-rev has in predicting 30-day mortality may have significant implications in multidisciplinary decision making.

Role of epidural disease in local control of spinal metastases treated with stereotactic body radiation therapy

Spinal metastases can be contained in the bone or have epidural spread. Whether the extent of epidural involvement changes tumor response to therapy is unknown. The decision of when to treat disease progression with focal radiation therapy with or without surgery vs. systemic therapy is debated. The present study compared outcomes and local tumor control after stereotactic body radiation therapy (SBRT) between patients with spine metastases localized to the bone (Bilsky 0) vs. patients with mild epidural spread (Bilsky 1). A retrospective analysis of a prospectively maintained database of adult oncological patients who underwent SBRT to the spine at a single, large, tertiary care facility from August 2010 to January 2021 was performed. Patients with Bilsky grades 1a, 1b and 1c were grouped and compared. Approximately half (53.7%) of the 255 patients identified had Bilsky grade 1 epidural disease. Of the 311 spine treatment sites, 86 (27.7%) had a radiosensitive histology, 116 (37.3%) had intermediate radiosensitivity and 109 (35.0%) had a radioresistant histology. Patients with Bilsky grade 1 were more predisposed to receive surgery followed by SBRT compared with those with Bilsky grade 0 (21.0% vs. 6.3%; P=0.0002). Patients with Bilsky grade 0 compression had 92.0% local control at 12 months and 85.8% local control at 24 months; patients with Bilsky grade 1 compression had 85.6% local control at 12 months and 77.6% local control at 24 months. Biologically effective dose and infield progression between patients presenting with Bilsky grade 0 and 1 compression were not statistically different. Local control rates did not differ significantly between Bilsky grade 0 and grade 1 patients following treatment with spinal SBRT. However, patients with grade 1 disease were more likely to receive surgery before SBRT. Overall, evidence indicates that patients may benefit from treatment with SBRT before epidural disease progresses to requiring separation surgery.

Impact of instrumentation material on local recurrence: a case-matched series using carbon fiber-PEEK vs. titanium

PURPOSE

Spine metastases are a major burden of oncologic care, contributing to substantial morbidity. A well-established treatment paradigm for patients with metastatic epidural spinal cord compression includes separation surgery followed by stereotactic body radiotherapy (SBRT). Innovations in implant technology have brought about the incorporation of Carbon fiber-reinforced polyetheretherketone (CFR-PEEK) instrumentation for spinal fixation. We present our experience of CFR-PEEK instrumentation, comparing outcomes and complication profiles with a matched cohort of titanium instrumented cases for spine metastatic disease.

METHODS

Oncology patients who underwent spinal fusion for metastatic spine disease from 2012 to 2023 were retrospectively reviewed. Ninety-nine cases with CFR-PEEK fusions were case-control matched with 50 titanium controls (2:1 ratio) based upon primary tumor type and spinal instability neoplastic score (SINS) location. Demographic, clinical, radiographic and progression free survival (PFS) were analyzed.

RESULTS

In the study years, 263 patients underwent spinal decompression and fusion, for which 148 patients met predetermined inclusion criteria. Of these, 49 had titanium instrumentation, and 99 had CFR-PEEK. Complication profiles, including hardware failure and infection were similar between the groups. There was no significant difference in PFS between all CFR-PEEK and titanium patients (143 days versus 214 days; p = 0.41). When comparing patients in which recurrence was noted, CFR-PEEK patients had recurrence detected two times earlier than titanium patients (94 days versus 189 days; p = 0.013).

CONCLUSION

In this case matched cohort, CFR-PEEK demonstrated decreased overall PFS suggestive of earlier local recurrence identification. Long-term studies are warranted for better evaluation of the impact on survival and systemic disease progression.

Can Survival Scoring Systems for Spinal Metastases be Used to Predict Postoperative Neurologic Recovery? A Retrospective Study on 204 Patients With Thoracolumbar Metastases Treated at a Tertiary Center

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Scoring systems for metastatic disease of the spine are used to select patients for surgical treatment based on survival estimation, but it is unknown whether they can be used to predict the outcome of surgery. This study aims to investigate the association between two widely used prognostic scores and the neurologic function after surgery.

METHODS

Retrospective analysis of 204 patients with thoracolumbar metastases treated with decompressive surgery at Karolinska University Hospital (2001-2020). Modified Bauer and Tokuhashi scores were categorized based on surgical indication, and post-operative neurological function was assessed using the Frankel scale at two different post-surgery intervals.

RESULTS

Modified Bauer scores ≥2 yielded higher late follow-up Frankel scores (3.9 ± 1.1) than scores <2 (3.5 ± 1.1), P = .03. Modified Tokuhashi scores ≥9 correlated with higher Frankel scores (4.5 ± .9) than scores <9 (3.5 ± 1.1), P < .0001. Both scoring systems positively predicted neurological outcomes at late follow-up, with odds ratios of 1.6 (P = .03) for Bauer and 9.2 (P < .0001) for Tokuhashi. However, only Tokuhashi predicted ambulatory function at late follow-up (P < .0001), demonstrating its utility in prognosticating post-surgical mobility.

CONCLUSION

Higher modified Bauer and Tokuhashi scores were associated with better neurologic function at last follow-up, as well as greater likelihood of being able to walk again. The Tokuhashi score was found to be more accurate than the modified Bauer score in predicting the neurological outcome after surgery.

Clinical evaluation, diagnosis, and decision-making for metastatic spine tumors: WFNS spine committee recommendations

INTRODUCTION

Spinal metastases are a significant concern for patients with advanced cancer, leading to pain, neurological deficits, and reduced quality of life. They occur in up to 70% of cancer patients, with the vertebral column being the most common osseous site for metastatic disease1-3. An approximate 10% of patients with vertebral body metastases eventually develop spinal cord compression, which can potentially cause severe and permanent disability4-6. This article aims to summarize the consensus statements developed by the World Federation of Neurosurgical Societies (WFNS) Spine Committee on the clinical evaluation, diagnosis, and decision-making for metastatic spine tumors.

METHODS

A systematic literature search was conducted in PubMed and Google Scholar from 2014 to 2023 using the search terms "clinical evaluation" + "spine metastases," "spine metastases" + "diagnosis," and "spine metastases" + "decision making" + "treatment." Based on the review of this literature, six members of the WFNS Spine Committee developed five consensus statements using the Delphi method, which were voted on during two rounds of voting at two international meetings.

RESULTS

We agree that a high index of suspicion is required for early detection and diagnosis of spinal metastasis in cancer patients and adult patients more than 60 years presenting with new onset fractures / neurological deficits. Pain is the most common symptom followed by motor deficit. Bowel and bladder dysfunction is noted in nearly half of patients with metastatic spinal cord compression. An effective treatment for spinal metastases should be able to achieve pain relief, tumor control, prevention of neurological compromise and treat instability. Separation surgery combined with SRS is an effective treatment for spinal metastases.

CONCLUSION

These consensus statements provide evidence-based guidelines for clinical evaluation, diagnosis, and decision-making in patients with metastatic spine tumors.

Improving the clinical meaning of surrogate endpoints: An empirical assessment of clinical progression in phase III oncology trials

Disease progression in clinical trials is commonly defined by radiologic measures. However, clinical progression may be more meaningful to patients, may occur even when radiologic criteria for progression are not met, and often requires a change in therapy in clinical practice. The objective of this study was to determine the utilization of clinical progression criteria within progression-based trial endpoints among phase III trials testing systemic therapies for metastatic solid tumors. The primary manuscripts and protocols of phase III trials were reviewed for whether clinical events, such as refractory pain, tumor bleeding, or neurologic compromise, could constitute a progression event. Univariable logistic regression computed odds ratios (OR) and 95% CI for associations between trial-level covariates and clinical progression. A total of 216 trials enrolling 148,190 patients were included, with publication dates from 2006 through 2020. A major change in clinical status was included in the progression criteria of 13% of trials (n = 27), most commonly as a secondary endpoint (n = 22). Only 59% of trials (n = 16) reported distinct clinical progression outcomes that constituted the composite surrogate endpoint. Compared with other disease sites, genitourinary trials were more likely to include clinical progression definitions (16/33 [48%] vs. 11/183 [6%]; OR, 14.72; 95% CI, 5.99 to 37.84; p < .0001). While major tumor-related clinical events were seldom considered as disease progression events, increased attention to clinical progression may improve the meaningfulness and clinical applicability of surrogate endpoints for patients with metastatic solid tumors.

Incidence, epidemiology, radiology, and classification of metastatic spine tumors: WFNS Spine Committee recommendations

Spinal metastasis (SMs) are the most encountered tumors of the spine. Their occurrence is expected roughly around one to two years after primary tumor diagnosis. Since the advent of Magnetic Resonance Imaging (MRI), this technology has been considered the gold standard for SMs diagnosis and characterization due to its precise ability to comprehend the rate of soft tissue compression/invasion (dural sac/nervous tissue), which is one of the main drivers of management strategies. Computed Tomography (CT) remains unbeatable when a detailed bony anatomy and instability assessment is searched. Nuclear medicine technologies may have a role in diagnosis when standard MR or CT study findings are inconclusive or when the extent of the systemic metastatic disease is studied. The main objective of this study is to offer an update on the epidemiology and radiology of spinal metastasis (SMs), endorsed by the WFNS Spine Committee. A systematic review of the literature of the last ten years gave 1531 results with "spine/spinal metastatic tumors/metastasis AND radiology OR imaging OR classification" as search strings in all fields, of which 56 papers were fully analyzed. The results were discussed and voted on in two consensus meetings of the WFNS (World Federation of Neurosurgical Societies) Spine Committee, reaching a positive or negative consensus using the Delphi method. The committee stated nine recommendations on two main topics: (1) Incidence and epidemiology of SMs; (2) Radiology and classifications of SMs.

Complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors: WFNS spine committee recommendations

OBJECTIVE

This review aims to formulate the most current, evidence-based recommendations regarding complication avoidance, rehabilitation, pain therapy and palliative care for patients with metastatic spine tumors.

METHODS

A systematic literature search in PubMed and MEDLINE, and was performed from 2013 to 2023 using the search terms "complications" + "spine metastases", "spine metastases" + + "rehabilitation", "spine metastases" + "pain therapy" + "palliative care". Screening criteria resulted in 35, 15 and 56 studies respectively that were analyzed. Using the Delphi method and two rounds of voting at two separate international meetings, nine members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated nine final consensus statements.

RESULTS

Preoperative assessment for complications following surgery in patients with metastatic spine tumors should include estimation of Karnofsky score, site of primary tumor, number of spinal and visceral metastasis, ASA score and preoperative Hb (Hemoglobin) value. Complication risk factors are age > 65 years, preoperative ASA score of 3 and 4 and greater operative blood loss. Pain management using WHO analgesic concept and early mobilization are needed, starting with non-opioids, weak opioids followed by strong opioids. Morphine is the first choice for moderate to severe pain whereas IV-PCA may be used for severe breakthrough pain with monitoring. Use of bisphosphonates is considered in cases of non-localized pain and not accessible radiation therapy.

CONCLUSIONS

These nine final consensus statements provide current, evidence-based guidelines on complication avoidance, rehabilitation, pain therapy and palliative care for patients with spinal metastases.

Diagnostic accuracy of imaging modalities for detection of spinal metastases: a systematic review and meta-analysis

PURPOSE

Detecting spinal metastases is highly relevant in patients with oncological disorders as it can affect the staging and treatment of their disease. We aimed to evaluate the diagnostic performance of computed tomography (CT), magnetic resonance imaging (MRI), FDG positron emission tomography (PET)/CT, bone scintigraphy (BS), and single-photon emission computed tomography (SPECT) for spinal metastases detection.

METHODS

Medline, EMBASE, and Web of Science were systematically searched until March 2024 for diagnostic accuracy studies on spinal metastases detection (PROSPERO-registration: CRD42024540139). Data extraction and quality assessment using the QUADAS-2 tool were performed by two independent reviewers. Using bivariate random effects modeling, pooled sensitivities, specificities, and diagnostic odds ratios (DOR) were calculated, and hierarchical summary operating curves were constructed.

RESULTS

Twenty-five studies (49 datasets), encompassing 3102 patients were included. Per-patient pooled sensitivities of CT, MRI, PET/CT, BS and SPECT were 70%, 93%, 82%, 75%, and 84%, respectively. Pooled specificities were 74%, 85%, 75%, 92%, and 81%, respectively. Per-lesion pooled sensitivities of CT, MRI, PET/CT, BS and SPECT were 76%, 91%, 92%, 77%, and 92%, respectively. Pooled specificities were 91%, 94%, 85%, 52%, and 86%, respectively. MRI had the highest DOR in per patient and lesion analyses.

CONCLUSION

MRI had highest diagnostic accuracy for spinal metastases detection on patient and lesion level, suggesting a broader use in addition to the routine staging CT, at least in patients at high risk and where the detection of a spinal metastasis could alter therapy decisions. Herein, results should be considered with the limitations of each modality.

Separation surgery for metastatic spine tumors: How less became more

Metastatic epidural spinal cord compression (MESCC) is an increasingly common clinical entity in cancer patients and is associated with significant morbidity and neurologic sequalae. Management of MESCC has undergone many significant paradigms shifts over the past 50 years and was at times managed exclusively with either surgery or radiation. Historically, aggressive surgical techniques to achieve en bloc or intralesional gross tumor resections were pursued but were associated with significant morbidity and poor tumor control rates when combined with conventional external beam radiation. However, improvements in radiation treatment delivery in the form of stereotactic body radiation therapy have allowed for the safe delivery of high-dose conformal photon beam radiation providing histology-independent ablative responses. This shifted the goals of surgery away from maximal tumor resection toward simple spinal cord decompression with reconstitution of the thecal to create a tumor target volume capable of being irradiated within the constraints of spinal cord tolerance. This new approach of creating space between the thecal sac and the tumor was termed separation surgery and when combined with postoperative SBRT, it is referred to as hybrid therapy. Herein, we will describe the evolution of the management of MESCC, the technique of separation surgery and its outcomes, and finish with an illustrative case example.

Advances in imaging modalities for spinal tumors

The spinal cord occupies a narrow region and is tightly surrounded by osseous and ligamentous structures; spinal tumors can damage this structure and deprive patients of their ability to independently perform activities of daily living. Hence, imaging is vital for the prompt detection and accurate diagnosis of spinal tumors, as well as determining the optimal treatment and follow-up plan. However, many clinicians may not be familiar with the imaging characteristics of spinal tumors due to their rarity. In addition, spinal surgeons might not fully utilize imaging for the surgical planning and management of spinal tumors because of the complex heterogeneity of these lesions. In the present review, we focus on conventional and advanced spinal tumor imaging techniques. These imaging modalities include computed tomography, positron emission tomography, digital subtraction angiography, conventional and microstructural magnetic resonance imaging, and high-resolution ultrasound. We discuss the advantages and disadvantages of conventional and emerging imaging modalities, followed by an examination of cutting-edge medical technology to complement current needs in the field of spinal tumors. Moreover, machine learning and artificial intelligence are anticipated to impact the application of spinal imaging techniques. Through this review, we discuss the importance of conventional and advanced spinal tumor imaging, and the opportunity to combine advanced technologies with conventional modalities to better manage patients with these lesions.

Stereotactic body radiotherapy for treatment of spinal metastasis: A systematic review of the literature

Background

Advances in local and systemic therapies continue to improve overall survival for patients with cancer, increasing the incidence of spine metastases. Up to 15% of patients with solid tumors develop spinal metastases. Spinal metastases can be particularly devastating for quality of life given the potential pain, neurological deficits from spinal cord compression or cauda equina syndrome, spinal instability, and pathological fractures that may result. Stereotactic body radiotherapy (SBRT) with or without adding less invasive surgical techniques for stabilization or separation has gained favor. SBRT uses smaller, more precise treatment volumes, allowing for higher doses per fracture, thus increasing ablative abilities.

Methods

We conducted a systematic review using MEDLINE, Embase (Elsevier), and Web of Science to identify all articles investigating the effectiveness of SBRT in providing local disease control, pain control, and relief of spinal cord compression for patients with metastatic disease of the spine.

Results

The review yielded 84 articles that met inclusion criteria. The evidence indicates SBRT provides excellent local control and pain control for patients with spine metastesis, and this remains true for patients with spinal cord compression managed with surgical separation followed by postoperative spine SBRT.

Conclusion

While not all patients are appropriate candidates for SBRT, carefully considering appropriate frameworks that consider the patient's overall prognosis can guide a multidisciplinary team toward the patients who will benefit the most from this treatment modality.

Racial and ethnic disparities in reception of muscle flap closure during oncologic spinal surgery

BACKGROUND

Racial disparities persist in surgical outcomes after spine surgery for primary and metastatic cancers. Muscle flap closure of spinal defects after oncologic resection has been shown to reduce wound complication rate with favorable cost-effectiveness. It is currently unknown whether racial disparities may affect the reception of this treatment.

METHODS

Spinal surgery procedures for tumor resection and subsequent reconstruction were identified in the 2011-2022 National Surgical Quality Improvement Program databases. Cases were propensity score matched for covariates like age, comorbidities, number of vertebral levels reconstructed, and length of stay to isolate the predictive impact of race on reception of muscle flap closure (p < 0.05).

RESULTS

A total of 9467 patients who underwent oncologic spine surgery and had known race and ethnicity were identified in the final cohort. Two hundred thirty-two (2.5%) cases included muscle flap closure during the index surgery. After matching (n = 4196), minority race/ethnicity was associated with lower rates of muscle flap closure (2.2%) than non-Hispanic White race/ethnicity (3.8%) (p = 0.0037). Upon weighted univariate logistic regression, minority racial and ethnic identification also predicted lower likelihood of muscle flap closure (OR: 0.57, 95% CI: 0.52-0.63, p < 0.001). Among patients who received muscle flap closure, the overall rate of all major or minor thirty-day postoperative complications was not different depending on race and ethnicity (p > 0.05).

CONCLUSION

There are evident racial disparities in the reception of muscle flap closure after oncologic spine surgery. Further work may investigate the role of intersecting socioeconomic factors like insurance status and hospital characteristics.

LAY SUMMARY

Muscle flap closure is a surgical technique within plastic surgery that has been associated with lower rates of complications after spine surgery to remove tumors. Our study shows that minority racial and ethnic groups are less likely on average to receive muscle flap closure.

Remineralization of lytic spinal metastases after radiation therapy - A retrospective cohort study comparing conventional external beam radiation therapy with stereotactic ablative body radiation

Introduction

Osteolytic spinal metastases (SM) have a higher risk of fracture. In this study we aim to confirm the remineralization of lytic SM after radiation therapy. Secondary the influence of SBRT compared to cEBRT and tumor type will be analyzed.

Methods

A retrospective cohort study was performed.

Results

87 patients, 100 SM were included. 29 received SBRT, 71 cEBRT. Most common primary tumors were breast (35 %), lung (26 %) and renal (11 %). Both cEBRT and SBRT resulted in a significant increase of bone mineral density (BMD) (83.76 HU ± 5.72 → 241.41 HU ± 22.58 (p < 0.001) and 82.45 ± 9.13 → 179.38 ± 47.83p = 0.026). There was a significant increase in absolute difference of BMD between the SM and reference vertebrae (p < 0.001). There was no significant difference between SBRT and cEBRT. There was no increase of BMD in renal lytic SM after radiation therapy (pre-treatment: 85.96 HU ± 19.07; 3 m 92.00 HU ± 21.86 (p = 0.882); 6 m 92.06 HU ± 23.94 (p = 0.902); 9 m 70.44 HU ± 7.45 (p = 0.213); 12 m 98.08 HU ± 11.24 (p = 0.740)). In all other primary tumors, a significant increase of BMD after radiation therapy was demonstrated (p < 0,05).

Conclusion

We conclude that the BMD of lytic SM increases significantly after radiation therapy. Lytic SM of primary renal tumors are the exception; there is no significant remineralization of renal lytic SM after radiation therapy. There is no benefit of SBRT over cEBRT in this remineralization. These findings should be taken into account when deciding on surgery in the potentially unstable group defined by the spinal instability neoplastic score.

Keeping it "straight": how to do spinal tumor ablation with vertebral augmentation

This technical review provides a comprehensive overview of spinal tumor ablation and vertebral augmentation. These percutaneous minimally invasive procedures offer significant survival and palliative pain relief benefits for patients with pathological vertebral fractures. Vertebral augmentation, which includes vertebroplasty and kyphoplasty, involves injecting cement into fractured vertebral bodies to restore height. While vertebroplasty involves the direct injection of cement into a fractured vertebral body, kyphoplasty involves using a balloon to create a low-pressure cavity to allow for cement injection to restore the vertebral body height. Over the years, this technique has evolved into a straightforward process, though it presents certain technical challenges discussed in this article.

Remote Hepatocellular Carcinoma Recurrence to Lumbar Spine Post Orthotopic Liver Transplantation-A Report of Two Cases and a Review of the Literature

Late recurrence of hepatocellular carcinoma (HCC) following orthotopic liver transplant (OLT) is infrequently reported, and among cases, those isolated to the spine are rare. Prognoses are poor for this patient population, and no work has been undertaken to create uniform guidelines for management. Here, we report two cases of late recurrent HCC to the spine after OLT and favorable survival outcomes following intervention.

The Spinal Instability Neoplastic Score correlates with epidural spinal cord compression -a retrospective cohort of 256 surgically treated patients with spinal metastases

BACKGROUND

Bone metastases can compromise the integrity of the spinal canal and cause epidural spinal cord compression (ESCC). The Spinal Instability Neoplastic Score (SINS) was developed in order to evaluate spinal instability due to a neoplastic process. The SINS has reached wide acceptance among clinicans but its prognostic value is still controversial. The aim was to investigate the correlation between the SINS and ESCC and the association between SINS and ambulation before and survival after surgery.

METHODS

Correlations were assessed between SINS and grades of ESCC in patients who underwent spine surgery for spinal metastases. CT and MRI were used to calculate SINS and the grades of ESCC respectively. Correlations were analyzed with the Spearman's correlation test. Postoperative survival was estimated with Kaplan-Meier analysis and survival curves were compared with the log-rank test. The Cox proportional hazard model was used to assess the effect of prognostic variables including age, ambulation before surgery, SINS, and the Karnofsky Performance Status (KPS) as covariates.

RESULTS

The study included 256 patients (196 men and 60 women) with a median age of 70 (24-88) years. The mean SINS was 10. One hundred fifty-two patients (59%) had lost ambulation before surgery. One hundred and one patients had grades 0-2 and 155 patients had grade 3 according to the ESCC-scale. SINS correlated with the grades of ESCC (p = 0.001). The SINS score was not associated with ambulation before surgery (p = 0.63). The median postoperative survival was 10 months, and there was no difference in postoperative survival between the SINS categories (p = 0.25). The ability to walk before surgery and a high KPS were associated with longer postoperative survival.

CONCLUSION

SINS correlated with grades of ESCC, which implies that higher SINS may be considered as an indicator of risk for developing ESCC. The SINS was not associated with ambulation before or survival after surgery.

Spinal Metastases of the Vertebrae: Three Main Categories of Pain

Oncologic back pain, infection, inflammation, and trauma are the only specific etiologies of chronic low back pain (CLBP) in contrast to most patients who have non-specific CLBP. In oncologic patients developing CLBP, it is critically important to perform further investigation to exclude spinal metastases (SM).The incidence of cancer is increasing, with 15.7-30% developing SM. In the case of symptomatic SM, we can distinguish three main categories: tumor pain; mechanical pain due to instability, with or without pathologic fractures; and metastatic epidural spinal cord compression (MESCC) or radicular compression. Treatment of SM-related pain is dependent on these categories and consists of symptomatic treatment, target therapy to the bone, radiotherapy, systemic oncologic treatment, and surgery. The care for SM is a multidisciplinary concern, with rapid evolutions in all specialties involved. It is of primordial importance to incorporate the knowledge of specialists in all participating disciplines, such as oncology, radiotherapy, and spinal surgery, to determine the adequate treatment to preserve ambulatory function and quality of life while limiting the burden of treatment if possible. Awareness of potential SM is the first and most important step in the treatment of SM-related pain. Early diagnosis and timely treatment could prevent further deterioration. In this review, we explore the pathophysiology and symptomatology of SM and the treatment options for SM-related pain: tumor pain; mechanical pain due to instability, with or without pathologic fractures; and MESCC or radicular compression.

A Multidisciplinary Update on Treatment Modalities for Metastatic Spinal Tumors with a Surgical Emphasis: A Literature Review and Evaluation of the Role of Artificial Intelligence

Spinal metastases occur in up to 40% of patients with cancer. Of these cases, 10% become symptomatic. The reported incidence of spinal metastases has increased in recent years due to innovations in imaging modalities and oncological treatments. As the incidence of spinal metastases rises, so does the demand for improved treatments and treatment algorithms, which now emphasize greater multidisciplinary collaboration and are increasingly customized per patient. Uniquely, we discuss the potential clinical applications of AI and NGS in the treatment of spinal metastases. Material and Methods: A PubMed search for articles published from 2000 to 2023 regarding spinal metastases and artificial intelligence in healthcare was completed. After screening for relevance, the key findings from each study were summarized in this update. Results: This review summarizes the evidence from studies reporting on treatment modalities for spinal metastases, including minimally invasive surgery (MIS), external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), CFR-PEEK instrumentation, radiofrequency ablation (RFA), next-generation sequencing (NGS), artificial intelligence, and predictive models.

Boron neutron capture therapy delays the decline in neurological function in a mouse model of metastatic spinal tumors

Metastatic spinal tumors are increasingly prevalent due to advancements in cancer treatment, leading to prolonged survival rates. This rising prevalence highlights the need for developing more effective therapeutic approaches to address this malignancy. Boron neutron capture therapy (BNCT) offers a promising solution by delivering targeted doses to tumors while minimizing damage to normal tissue. In this study, we evaluated the efficacy and safety of BNCT as a potential therapeutic option for spine metastases in mouse models induced by A549 human lung adenocarcinoma cells. The animal models were randomly allocated into three groups: untreated (n = 10), neutron irradiation only (n = 9), and BNCT (n = 10). Each mouse was administered 4-borono-L-phenylalanine (250 mg/kg) intravenously, followed by measurement of boron concentrations 2.5 h later. Overall survival, neurological function of the hindlimb, and any adverse events were assessed post irradiation. The tumor-to-normal spinal cord and blood boron concentration ratios were 3.6 and 2.9, respectively, with no significant difference observed between the normal and compressed spinal cord tissues. The BNCT group exhibited significantly prolonged survival rates compared with the other groups (vs. untreated, p = 0.0015; vs. neutron-only, p = 0.0104, log-rank test). Furthermore, the BNCT group demonstrated preserved neurological function relative to the other groups (vs. untreated, p = 0.0004; vs. neutron-only, p = 0.0051, multivariate analysis of variance). No adverse events were observed post irradiation. These findings indicate that BNCT holds promise as a novel treatment modality for metastatic spinal tumors.

Clinical Oversight and Delayed Diagnosis of a Pathological Compression Fracture Causing Paraplegia

While osteoporosis is the primary cause of vertebral compression fractures (VCFs), it's crucial to promptly recognize pathological fractures through comprehensive diagnostic tests, including vertebral biopsies, to determine the exact etiology. For instance, a 66-year-old male with osteoporosis experienced worsening lower limb weakness and back pain after an initial vertebroplasty for a T12 compression fracture. Subsequent MRI revealed severe circumferential extradural compression at T12, leading to further surgeries that eventually uncovered metastatic adenocarcinoma from a pancreatic tumor. This case highlights the importance of precise diagnosis through vertebral biopsy and the necessity of sufficient ventral decompression or corpectomy, coupled with extensive laminectomy, to address severe neurological impairments like paraplegia. Prompt and accurate interventions can significantly improve patient outcomes and quality of life.

Intraoperative radiotherapy combined with spinal stabilization surgery-a novel treatment strategy for spinal metastases based on a first single-center experiences

INTRODUCTION

Current treatment of spinal metastases (SM) aims on preserving spinal stability, neurological status, and functional status as well as achieving local control. It consists of spinal surgery followed by radiotherapy and/or systemic treatment. Adjuvant therapy usually starts with a delay of a few weeks to prevent wound healing issues. Intraoperative radiotherapy (IORT) has previously been successfully applied during brain tumor, breast and colorectal carcinoma surgery but not in SM, including unstable one, to date. In our case series, we describe the feasibility, morbidity and mortality of a novel treatment protocol for SM combining stabilization surgery with IORT.

METHODS

Single center case series on patients with SM. Single session stabilization by navigated open or percutaneous procedure using a carbon screw-rod system followed by concurrent 50 kV photon-IORT (ZEISS Intrabeam). The IORT probe is placed via a guide canula using navigation, positioning is controlled by IOCT or 3D-fluroscopy enabling RT isodose planning in the OR.

RESULTS

15 (8 female) patients (71 ± 10y) received this treatment between 07/22 and 09/23. Median Spinal Neoplastic Instability Score was 8 [7-10] IQR. Most metastasis were located in the thoracic (n = 11, 73.3%) and the rest in the lumbar (n = 4, 26.7%) spine. 9 (60%) patients received open, 5 (33%) percutaneous stabilization and 1 (7%) decompression only. Mean length of surgery was 157 ± 45 min. Eleven patients had 8 and 3 had 4 screws placed. In 2 patients radiotherapy was not completed due to bending of the guide canula with consecutive abortion of IORT. All other patients received 8 Gy isodoses at mdn. 1.5 cm [1.1-1.9, IQR] depth during 2-6 min. The patients had Epidural Spinal Cord Compression score 1a-3. Seven patients (46.7%) experienced adverse events including 2 surgical site infection (one 65 days after surgery).

CONCLUSION

50 kV photon IORT for SM and consecutive unstable spine needing surgical intervention is safe and feasible and can be a promising technique in selected cases.

Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment

Chronic low back pain (cLBP) is the most frequently reported cause of years lived with disability. Identifying the anatomical structures or dysfunction contributing to patients' symptoms is critical to guiding treatment. The etiology of back pain and differential diagnosis is often broad, ranging from non-degenerative cLBP (trauma, tumor, inflammation, infection, etc.) to degenerative (also described as nonspecific) cLBP. After eliminating suspicion for more insidious causes of cLBP, a thorough investigation can be conducted in an attempt to identify a source of degenerative cLBP. Degenerative cLBP can originate from many sources, and a detailed understanding of the structures potentially involved is invaluable for an accurate diagnosis. This review article aims to provide a broad overview of the utility of clinical history, physical exam findings, imaging findings, and diagnostic procedures in identifying the cause of patients' cLBP. We provide a framework to help guide clinicians by dividing the structures into groups as follows: anterior vertebral column, posterior vertebral column, and extra-vertebral pain. For each condition listed, we touch on the treatment options that can be considered.

Baseline Frailty Measured by the Risk Analysis Index and 30-Day Mortality After Surgery for Spinal Malignancy: Analysis of a Prospective Registry (2011-2020)

OBJECTIVE

To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection.

METHODS

SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001).

CONCLUSION

Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

Mexican Multicenter Experience of Metastatic Spinal Disease

Background Spinal metastatic disease is a silent progressive cancer complication with an increasing prevalence worldwide. The spine is the third most common site where solid tumors metastasize. Complications involved in spinal metastasis include root or spinal cord compression, progressing to a declining quality of life as patient autonomy reduces and pain increases. The main objective of this study is to report the incidence of patients and typology of spinal metastases in three reference centers in Mexico. Methodology Retrospective cohorts of patients diagnosed with spinal metastases from January 2010 to February 2017 at the National Cancer Institute, National Rehabilitation Institute, and the Traumatology and Orthopedics Hospital "Lomas Verdes" in Mexico City were analyzed. Results A total of 326 patients (56% males) with spinal metastases were reported. The mean age was 58.06 ± 14.05 years. The main sources of spinal metastases were tumors of unknown origin in 53 (16.25%) cases, breast cancer in 67 (20.5%) cases, prostate cancer in 59 (18%) cases, myeloma in 24 (7.4%) cases, and lung cancer in 23 (7.1%) cases. Conclusions The data obtained in this analysis delivers an updated standpoint on Mexico, providing the opportunity to distinguish the current data from global references. Collecting more epidemiological information for better recording of cancer and its associated complications, as well as further studies on them, is necessary.

Promoting postoperative recovery in patients with metastatic epidural spinal cord compression based on the concept of ERAS: a multicenter analysis of 304 patients

BACKGROUND CONTEXT

Enhanced recovery after surgery (ERAS) has proven beneficial for patients undergoing orthopedic surgery. However, the application of ERAS in the context of metastatic epidural spinal cord compression (MESCC) remains undefined.

PURPOSE

This study aims to establish a medical pathway rooted in the ERAS concept, with the ultimate goal of scrutinizing its efficacy in enhancing postoperative outcomes among patients suffering from MESCC.

STUDY DESIGN/SETTING

An observational cohort study.

PATIENT SAMPLE

A total of 304 patients with MESCC who underwent surgery were collected between January 2016 and January 2023 at two large tertiary hospitals.

OUTCOME MEASURES

Surgery-related variables, patient quality of life, and pain outcomes. Surgery-related variables in the study included surgery time, surgery site, intraoperative blood loss, and complication.

METHODS

From January 2020 onwards, ERAS therapies were implemented for MESCC patients in both institutions. Thus, the ERAS cohort included 138 patients with MESCC who underwent surgery from January 2020 to January 2023, whereas the traditional cohort consisted of 166 patients with MESCC who underwent surgery from January 2016 to December 2019. Clinical baseline characteristics, surgery-related features, and surgical outcomes were collected. Patient quality of life was evaluated using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and pain outcomes were assessed using the Visual Analogue Scale (VAS).

RESULTS

Comparison of baseline characteristics revealed that the two cohorts were similar (all p>.050), indicating comparable distribution of clinical characteristics. In terms of surgical outcomes, patients in the ERAS cohort exhibited lower intraoperative blood loss (p<.001), shorter postoperative hospital stays (p<.001), lower perioperative complication rates (p=.020), as well as significantly shorter time to ambulation (P<0.001), resumption of regular diet (p<.001), removal of urinary catheter (p<.001), initiation of radiation therapy (p<.001), and initiation of systemic internal therapy (p<.001) compared with patients in the traditional cohort. Regarding pain outcomes and quality of life, patients undergoing the ERAS program demonstrated significantly lower VAS scores (p<.010) and higher scores for physical (p<.001), social (p<.001), emotional (p<.001), and functional (p<.001) well-being compared with patients in the traditional cohort.

CONCLUSIONS

The ERAS program, renowned for its ability to expedite postoperative recuperation, emerges as a promising approach to ameliorate the recovery process in MESCC patients. Not only does it exhibit potential in enhancing pain management outcomes, but it also holds the promise of elevating the overall quality of life for these individuals. Future investigations should delve deeper into the intricate components of the ERAS program, aiming to unravel the precise mechanisms that underlie its remarkable impact on patient outcomes.

Vertebral Compression Fracture After Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate Disruption

BACKGROUND AND OBJECTIVES

Vertebral compression fracture (VCF) is a common, but serious toxicity of spinal stereotactic body radiotherapy (SBRT). Several variables that place patients at high risk of VCF have previously been identified, including advanced Spinal Instability Neoplastic Score (SINS), a widely adopted clinical decision criterion to assess spinal instability. We examine the role of tumoral endplate (EP) disruption in the risk of VCF and attempt to incorporate it into a simple risk stratification system.

METHODS

This study was a retrospective cohort study from a single institution. Demographic and treatment information was collected for patients who received spinal SBRT between 2013 and 2019. EP disruption was noted on pre-SBRT computed tomography scan. The primary end point of 1-year cumulative incidence of VCF was assessed on follow-up MRI and computed tomography scans at 3-month intervals after treatment.

RESULTS

A total of 111 patients were included. The median follow-up was 18 months. Approximately 48 patients (43%) had at least one EP disruption. Twenty patients (18%) experienced a VCF at a median of 5.2 months from SBRT. Patients with at least one EP disruption were more likely to experience VCF than those with no EP disruption (29% vs 6%, P < .001). A nomogram was created using the variables of EP disruption, a SINS of ≥7, and adverse histology. Patients were stratified into groups at low and high risk of VCF, which were associated with 2% and 38% risk of VCF ( P < .001).

CONCLUSION

EP disruption is a novel risk factor for VCF in patients who will undergo spinal SBRT. A simple nomogram incorporating EP disruption, adverse histology, and SINS score is effective for quickly assessing risk of VCF. These data require validation in prospective studies and could be helpful in counseling patients regarding VCF risk and referring for prophylactic interventions in high-risk populations.

Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment

PURPOSE

Patients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection.

METHODS

From 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM.

RESULTS

The predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1-15.8) compared to 13 months (95% CI 7.7-14.2) for those with metachronous SM (p = 0.74).

CONCLUSIONS

Our findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Treatment and Management of the Clinical Manifestations of Advanced Breast Cancer

OBJECTIVES

People with advanced breast cancer (ABC) experience complex and debilitating physical symptoms of their disease that can have a profound effect on quality of life. This report provides an overview of the clinical manifestations related to different metastatic sites in ABC and potential oncologic emergencies.

DATA SOURCES

Date sources include peer-reviewed papers sourced in electronic databases (CINAHL, MEDLINE, Google Scholar) and national and international best practice guidelines.

CONCLUSION

People living with ABC experience multiple symptoms of disease that can impact on quality of life and physical functioning. The most common sites of metastatic disease are bone, lung, liver and brain. Clinical manifestations of ABC include pain, pathologic fractures, pleural effusions, and ascites. Potential oncologic emergencies related to these metastatic sites include hypercalcemia, malignant spinal cord compression, superior vena cava obstruction, and raised intracranial pressure.

IMPLICATIONS FOR NURSING PRACTICE

It is important for nurses to have informed knowledge and understanding of these clinical manifestations. This will enable them to be vigilant and perform targeted patient evaluation to assess signs and symptoms with a view to identifying potentially life-threatening emergencies and initiating interventions or appropriate referral or follow-up accordingly.

Incidence and radiotherapy treatment patterns of complicated bone metastases

Background

Despite the encouraging results of the SCORAD trial, single fraction radiotherapy (SFRT) remains underused for patients with complicated bone metastases with rates as low as 18-39%. We aimed to evaluate the incidence and treatment patterns of these metastases in patients being referred to a tertiary centre for palliative radiotherapy.

Materials and methods

We performed a retrospective review of all bone metastases treated at our centre from January 2013 until December 2017. Lesions were classified as uncomplicated or complicated. Complicated was defined as associated with (impending) fracture, existing spinal cord or cauda equina compression. Our protocol suggests using SFRT for all patients with complicated bone metastases, except for those with symptomatic neuraxial compression and a life expectancy of ≥28 weeks.

Results

Overall, 37 % of all bone metastases were classified as complicated. Most often as a result of an (impending) fracture (56 %) or spinal cord compression (44 %). In 93 % of cases, complicated lesions were located in the spine, most commonly originating from prostate, breast and lung cancer (60 %). Median survival of patients with complicated bone metastases was 4 months. The use of SFRT for complicated bone metastases increased from 51 % to 85 % over the study period, reaching 100 % for patients with the poorest prognosis.

Conclusions

Approximately 37 % of bone metastases are classified as complicated with the majority related to (impending) fracture. Patients with complicated bone metastases have a median survival of 4 months and were mostly treated with SFRT.

Enhancing the referral process for surgical management of spinal metastases: insights from a 12-year, bi-institutional study of 533 patients

Introduction

Delayed surgical management of spinal metastases (SMs) can have detrimental effects on patient survival and quality of life, leading to pain and potential neurological impairment. This study aimed to assess the impact of delayed referral for SMs on clinical outcomes by analyzing patients managed in emergency situations.

Methods

We retrospectively reviewed the data of all patients admitted on either emergency or elective basis who underwent surgery for the treatment of neoplastic spine lesions at our two institutions (tertiary referral neurosurgical units) between January 2008 and December 2019.

Results

We analyzed 210 elective (EGp) and 323 emergency patients (UGp); emergencies increased significantly over the 12-year period, with a Friday peak (39.3%) and frequent neurological impairment (61.6% vs. 20%). Among the UGp patients, 186 (7.5%) had a previously monitored primitive cancer, including 102 (31.6%) with known SMs. On admission, 71 of the 102 (69.9%) patients presented with neurological deficits. UGp patients were more likely to undergo a single decompression without fixation. Outcomes at the 3-month follow-up were significantly worse for UGp patients ([very] poor, 29.2 vs. 13.8%), and the median overall survival for UGp patients was statistically lower. Risk factors for patients with SM undergoing emergency management included short delay between onset of symptoms and first contact with a spine surgeon, and an initial motor deficit.

Conclusion

Many patients with previously identified metastases, including those with neurological deficits, are urgently referred. Optimization is needed in the oncology pathway, and all stakeholders must be made aware of the factors contributing to the improvement in the clinical and radiological identification of potential complications affecting patient survival and quality of life.

Emergency radiation therapy in modern-day practice: Now or never, or never again ?

Radiation therapy plays a fundamental role in oncological emergencies such as superior vena cava syndrome (SVCS) and metastatic epidural spinal cord compression (MESCC). These are two examples of critical complications of metastatic cancer in terms of pain and functional impact (respiratory and/or neurological). The aim of this review is to explore the current indications, treatment options and outcomes for emergency radiotherapy regarding to these complications.Regarding SVCS, studies are mostly retrospective and unanimously demonstrated a beneficial effect of radiotherapy on symptom relief. Spinal cord compression remains an indication for urgent radiotherapy, and should be combined with surgery when possible. The innovative stereotactic body radiotherapy (SBRT) showed promising results, however this technique requires small volumes and more time preparation and therefore is often unsuitable for SVCS and MESCC emergencies.This review concluded that radiotherapy has a central role to play within a multimodal approach for SVCS and MESCC treatment. Further prospective studies are needed to confirm the effectiveness of radiation and establish the criteria for selecting patients to benefit from this treatment option.

Contemporary trends in the incidence and timing of spinal metastases: A population-based study

Background

Spinal metastases are a significant complication of advanced cancer. In this study, we assess temporal trends in the incidence and timing of spinal metastases and examine underlying patient demographics and primary cancer associations.

Methods

In this population-based retrospective cohort study, health data from 2007 to 2019 in Ontario, Canada were analyzed (n = 37, 375 patients identified with spine metastases). Primary outcomes were annual incidence of spinal metastasis, and time to metastasis after primary diagnosis.

Results

The age-standardized incidence of spinal metastases increased from 229 to 302 cases per million over the 13-year study period. The average annual percent change (AAPC) in incidence was 2.2% (95% CI: 1.4% to 3.0%) with patients aged ≥85 years demonstrating the largest increase (AAPC 5.2%; 95% CI: 2.3% to 8.3%). Lung cancer had the greatest annual incidence, while prostate cancer had the greatest increase in annual incidence (AAPC 6.5; 95% CI: 4.1% to 9.0%). Lung cancer patients were found to have the highest risk of spine metastasis with 10.3% (95% CI: 10.1% to 10.5%) of patients being diagnosed at 10 years. Gastrointestinal cancer patients were found to have the lowest risk of spine metastasis with 1.0% (95% CI: 0.9% to 1.0%) of patients being diagnosed at 10 years.

Conclusions

The incidence of spinal metastases has increased in recent years, particularly among older patients. The incidence and timing vary substantially among different primary cancer types. These findings contribute to the understanding of disease trends and emphasize a growing population of patients who require subspecialty care.

The new clinical classification of metastatic spinal malignancies serves as a vital reference for surgical management: a retrospective case-control study

BACKGROUND

It is commonly accepted that surgical treatment is an essential component of the comprehensive management of metastatic spinal malignancies. However, up until now, the clinical classification of metastatic spinal malignancies has not been well-structured.

METHODS

After IRB approval, 86 patients with metastatic spinal malignancies were adopted. According to the vascular distribution, stability of vertebrae, and degree of nerve compression, metastatic spinal malignancies can be classified into five types. Tumors classified as type I typically appear in the vertebral body. Type II tumors are those that develop in the transverse processes, superior and inferior articular processes, and spinal pedicles. Type III denotes malignancies that are present in the spinous process and vertebral plate. Types IVa and IVb are included in type IV. Type IVa combines type I and type II, whereas type IVb combines type II and type III. Type V tumors are those of types I, II, and III that co-occur and spread in different directions into the spinal canal. 20 of included 86 patients who did not receive segmental arterial embolization were set as the non-embolization group. The embolization group included 24 patients who received segmental arterial embolization on both sides of the diseased vertebrae. 42 patients were included in the offending embolization group after receiving responsible arterial embolization. A surgical intervention was performed within 24 h following an embolization. Surgical intervention with the purpose of removing as much of the tumor as possible and providing an effective reconstruction of the spinal column.

RESULTS

In comparison with the non-embolization group and embolization group, the offending embolization group presented unique advantages in terms of bleeding volume (p<0.001), operation time (p<0.001), and local recurrence rate within 12 months (p=0.006).

CONCLUSION

By significantly reducing surgical trauma and local recurrence rate (12 months), responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies, are worthy of clinical dissemination.

Dynamic contrast-enhanced magnetic resonance imaging parameter changes as an early biomarker of tumor responses following radiation therapy in patients with spinal metastases: a systematic review

PURPOSE

This systematic review aims to assess and summarize the clinical values of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameter changes as early biomarkers of tumor responses following radiation therapy (RT) in patients with spinal metastases.

MATERIALS AND METHODS

A systematic search was conducted on five electronic databases: PubMed, Scopus, Science Direct, Cochrane, and Embase. Studies were included if they mentioned DCE-MRI parameter changes before and after RT in patients with spinal metastases with a correlation to tumor responses based on clinical and imaging criteria. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to assess study quality.

RESULTS

This systematic review included seven studies involving 107 patients. All seven studies evaluated the transfer constant (Ktrans), six studies evaluated the plasma volume fraction (Vp), three studies evaluated the extravascular extracellular space volume fraction, and two studies evaluated the rate constant. There were variations in the type of primary cancer, RT techniques used, post-treatment scan time, and median follow-up time. Despite the variations, however, the collected evidence generally suggested that significant differences could be detected in DCE-MRI parameters between before and after RT, which might reflect treatment success or failures in long-term follow-up. Responders showed higher reduction and lower values of Ktrans and Vp after RT. DCE-MRI parameters showed changes and detectable recurrences significantly earlier (up to 6 months) than conventional MRI with favorable diagnostic values.

CONCLUSION

The results of this systematic review suggested that DCE-MRI parameter changes in patients with spinal metastases could be a promising tool for treatment-response assessment following RT. Lower values and higher reduction of Ktrans and Vp after treatment demonstrated good prediction of local control. Compared to conventional MRI, DCE-MRI showed more rapid changes and earlier prediction of treatment failure.

Treatment strategies in vertebral metastasis. Need for multidisciplinary committees from the perspective of the surgeon. Narration of literatura

Improvements in cancer diagnosis and treatment have improved survival. Secondarily, the number of patients who present a vertebral metastasis and the number with some morbidity in relation to these metastases also increases. Vertebral fracture, root compression or spinal cord injury cause a deterioration of their quality of life. The objective in the treatment of the vertebral metastasis must be the control of pain, maintenance of neurological function and vertebral stability, bearing in mind that in most cases it will be a palliative treatment. The treatment of these complications needs a multidisciplinary approach, radiologists, interventional radiologists, oncologists and radiation therapists, spine surgeons, but also rehabilitation or pain units. Recent studies show that a multidisciplinary approach of these patients can improve quality of life and even prognosis. In the present article, a review and reading of the literature on the multidisciplinary management of these patients is carried out.

Bone Consolidation: A Practical Guide for the Interventional Radiologist

In recent years, interventional radiologists have been increasingly involved in the management of bone fractures resulting from benign (osteoporosis and trauma), as well as malignant (tumor-related impending or pathologic fractures) conditions. Interventional techniques used to fix fractures include image-guided osteoplasty, screw-mediated osteosynthesis, or combinations of both. In the present narrative review, we highlight the most common clinical scenarios that may benefit from such interventional techniques with specific focus on spine, pelvic ring, and long bones.

A deep learning-based technique for the diagnosis of epidural spinal cord compression on thoracolumbar CT

PURPOSE

To develop a deep learning (DL) model for epidural spinal cord compression (ESCC) on CT, which will aid earlier ESCC diagnosis for less experienced clinicians.

METHODS

We retrospectively collected CT and MRI data from adult patients with suspected ESCC at a tertiary referral institute from 2007 till 2020. A total of 183 patients were used for training/validation of the DL model. A separate test set of 40 patients was used for DL model evaluation and comprised 60 staging CT and matched MRI scans performed with an interval of up to 2 months. DL model performance was compared to eight readers: one musculoskeletal radiologist, two body radiologists, one spine surgeon, and four trainee spine surgeons. Diagnostic performance was evaluated using inter-rater agreement, sensitivity, specificity and AUC.

RESULTS

Overall, 3115 axial CT slices were assessed. The DL model showed high kappa of 0.872 for normal, low and high-grade ESCC (trichotomous), which was superior compared to a body radiologist (R4, κ = 0.667) and all four trainee spine surgeons (κ range = 0.625-0.838)(all p < 0.001). In addition, for dichotomous normal versus any grade of ESCC detection, the DL model showed high kappa (κ = 0.879), sensitivity (91.82), specificity (92.01) and AUC (0.919), with the latter AUC superior to all readers (AUC range = 0.732-0.859, all p < 0.001).

CONCLUSION

A deep learning model for the objective assessment of ESCC on CT had comparable or superior performance to radiologists and spine surgeons. Earlier diagnosis of ESCC on CT could reduce treatment delays, which are associated with poor outcomes, increased costs, and reduced survival.

[Translated article] Treatment strategies in vertebral metastasis. Need for multidisciplinary committees from the perspective of the surgeon. Narration of literature

Improvements in cancer diagnosis and treatment have improved survival. Secondarily, the number of patients who present a vertebral metastasis and the number with some morbidity in relation to these metastases also increase. Vertebral fracture, root compression or spinal cord injury cause a deterioration of their quality of life. The objective in the treatment of the vertebral metastasis must be the control of pain, maintenance of neurological function and vertebral stability, bearing in mind that in most cases it will be a palliative treatment. The treatment of these complications needs a multidisciplinary approach, radiologists, interventional radiologists, oncologists and radiation therapists, spine surgeons, but also rehabilitation or pain units. Recent studies show that a multidisciplinary approach of these patients can improve quality of life and even prognosis. In the present article, a review and reading of the literature on the multidisciplinary management of these patients is carried out.

Prognostic Factors Associated With Overall Survival in Breast Cancer Patients With Metastatic Spinal Disease

Introduction The spine is the third most frequent site of metastasis, after the lungs and liver, in breast cancer patients. The current treatment modality is based on the prognosis calculated according to multiple clinical features; therefore, multiple scores have been developed to make the therapeutic decision; however, there are no specific scores to take an adequate therapeutic approach in the treatment of vertebral metastases due to breast cancer. The aim of the study is to identify the prognostic factors associated with survival in breast cancer patients with spinal metastatic disease. Methods A retrospective cohort study was carried out at the National Cancerology Institute (INCAN) in Mexico City from January 2011 to December 2017. To this extent, 56 consecutive cases of patients with breast cancer were included. Multiple demographic, laboratory, and clinical variables were taken into account for the survival calculation. Kaplan-Meier graphs and log-rank tests were performed to observe significant differences by subgroups in survival, and Cox regression was used for multivariate analysis. Results Concerning the survival analysis, the patients who presented extra-spinal metastases, an unstable spine, and Frankel grade C had a statistically significantly worse prognosis. In the multivariate analysis, the variables included extra-spinal metastases, age >50 years, spinal instability, serum alkaline phosphatase, and CA 15.3 serum levels, finding statistical significance with a p=0.015. Conclusion Prognostic factors associated with shorter overall survival in breast cancer patients with metastatic spinal disease were the presence of extra-spinal metastases and spinal instability. Additionally, the use of the Tomita and Tokuhashi scores for patients with breast cancer and spinal metastases is not justified at present. The study should be continued with a larger population to decrease biases and obtain a more homogeneous sample, as well as to obtain a personalized score to determine a more efficient treatment for these patients.

Patients with progression of spinal metastases who present to the clinic have better outcomes compared to those who present to the emergency department

BACKGROUND

As cancer therapies have improved, spinal metastases are increasingly common. Resulting complications have a significant impact on patient's quality of life. Optimal methods of surveillance and avoidance of neurologic deficits are understudied. This study compares the clinical course of patients who initially presented to the emergency department (ED) versus a multidisciplinary spine oncology clinic and who underwent stereotactic body radiation therapy (SBRT) secondary to progression/presentation of metastatic spine disease.

METHODS

We performed a retrospective analysis of a prospectively maintained database of adult oncologic patients who underwent spinal SBRT at a single hospital from 2010 to 2021. Descriptive statistics and survival analyses were performed.

RESULTS

We identified 498 spinal radiographic treatment sites in 390 patients. Of these patients, 118 (30.3%) presented to the ED. Patients presenting to the ED compared to the clinic had significantly more severe spinal compression (52.5% vs. 11.7%; p < 0.0001), severe pain (28.8% vs. 10.3%; p < 0.0001), weakness (24.5% vs. 4.5%; p < 0.0001), and difficulty walking (24.5% vs. 4.5%; p < 0.0001). Patients who presented to the ED compared to the clinic were significantly more likely to have surgical intervention followed by SBRT (55.4% vs. 15.3%; p < 0.0001) compared to SBRT alone. Patients who presented to the ED compared to the clinic had a significantly quicker interval to distant spine progression (5.1 ± 6.5 vs. 9.1 ± 10.2 months; p = 0.004), systemic progression (5.1 ± 7.2 vs. 9.2 ± 10.7 months; p < 0.0001), and worse overall survival (9.3 ± 10.0 vs. 14.3 ± 13.7 months; p = 0.002).

CONCLUSION

The establishment of multidisciplinary spine oncology clinics is an opportunity to potentially allow for earlier, more data-driven treatment of their spinal metastatic disease.

Radiologic reporting of MRI-proven thoracolumbar epidural metastases on body CT: 12-Year single-institution experience

RATIONALE AND OBJECTIVES

Metastatic epidural masses are an important radiological finding. The purpose of this study is to determine factors associated with non-reporting of thoracolumbar epidural metastases on body CT.

MATERIALS AND METHODS

In a study population of 166 patients from a single institution over a 12-year period, 293 body CT examinations were identified which were performed within 30 days before or after a spine MRI diagnosis of epidural metastasis. Associations were sought between patient diagnosis, CT examination characteristics, reporting radiologist (n = 17), and lesion characteristics with respect to whether an epidural metastasis was reported on CT.

RESULTS

In retrospective consensus review comprised of 3 radiologists, epidural metastases reported on spine MRI were clearly visible in 80.5% (236/293) of body CT examinations, however 65.3% (154/236) of the body CT reports omitted reporting their presence, even in cases where there was a preceding MRI diagnosis within 30 days (65.4%, 74/113). The identity of the reporting radiologist was statistically significantly associated with the accurate diagnostic reporting of epidural metastasis on body CT (p = 0.04). The only lesion features which were statistically significantly associated with CT reporting were lesion volume (p = 0.03) on noncontrast CT, and lesion volume (p = 0.006) and percentage of spinal canal stenosis (p = 0.001) on intravenous contrast-enhanced CT. The presence or absence of intravenous contrast was not significantly associated with CT reporting (p = 1.0).

CONCLUSION

Using spine MRI as the reference standard for the presence of epidural tumor, the majority of body CT reports omit describing thoracolumbar epidural metastases which are clearly visible in retrospect.

Local Recurrence and Development of Spinal Cord Syndrome during Follow-Up after Surgical Treatment of Metastatic Spine Disease

BACKGROUND

Surgical decompression (SD), with or without posterior stabilization followed by radiotherapy, is an established treatment for patients with metastatic spinal disease with epidural spinal cord compression (ESCC). This study aims to identify risk factors for occurrence of neurological compromise resulting from local recurrence.

METHODS

All patients who received surgical treatment for metastatic spinal disease at our center between 2011 and 2022 were included in this study. Cases were evaluated for tumor entity, surgical technique for decompression (decompression, hemilaminectomy, laminectomy, corpectomy) neurological deficits, grade of ESCC, time interval to radiotherapy, and perioperative complications.

RESULTS

A total of 747 patients were included in the final analysis, with a follow-up of 296.8 days (95% CI (263.5, 330.1)). During the follow-up period, 7.5% of the patients developed spinal cord/cauda syndrome (SCS). Multivariate analysis revealed prolonged time (>35 d) to radiation therapy as a solitary risk factor (p < 0.001) for occurrence of SCS during follow-up.

CONCLUSION

Surgical treatment of spinal metastatic disease improves patients' quality of life and Frankel grade, but radiation therapy needs to be scheduled within a time frame of a few weeks in order to reduce the risk of tumor-induced neurological compromise.

Three-dimensional simulation/printing-assisted surgery for symptomatic metastatic epidural spinal cord compression of posterior column: efficacy assessment based on 2-year follow-up

Background

Surgical intervention is necessary for resolving the symptoms of the spinal cord and nerve compression caused by symptomatic metastatic epidural spinal cord compression. However, surgeons are constantly seeking ways to improve surgical efficiency and safety. This study aims to evaluate the efficacy of 3D simulation/printing-assisted surgery for symptomatic metastatic epidural spinal cord compression of the posterior column.

Methods

We retrospectively analyzed the clinical data of patients who underwent surgical treatment for symptomatic metastatic epidural spinal cord compression of the posterior column in our hospital from January 2015 to January 2020. The simulated group underwent a 3D digital simulation of the lesion area using imaging data before surgery. Twelve patients in the simulated group also received 3D printing, while the direct surgery group did not receive any 3D simulation or printing. All patients were followed up for at least 2 years. We collected clinical data, including operation time, intraoperative blood loss, pedicle screw adjustment rate, intraoperative fluoroscopy times, the incidence of dural injury and cerebrospinal fluid leakage, VAS score, postoperative neurological function improvement, and tumor recurrence. Statistical analysis was performed using SPSS23.0, and P < 0.05 was considered statistically significant.

Results

A total of 46 patients were included in this study, with 20 in the simulated group and 26 in the non-simulated group. The simulated group had better operation time, intraoperative blood loss, screw adjustment rate, fluoroscopy times, and incidence of dural injury/cerebrospinal fluid leakage compared to the non-simulated group. The VAS scores of the two groups improved significantly after the operation and at the last follow-up compared to before the operation. However, there was no statistically significant difference between the two groups. There was also no statistically significant difference in neurological function improvement between the two groups. In the simulated group, 25% of patients relapsed, while in the non-simulated group, 34.61% of patients relapsed. However, there was no statistical difference between the two groups.

Conclusion

Preoperative 3D simulation/printing-assisted surgery is a practical and feasible approach for treating symptomatic metastatic epidural spinal cord compression of the posterior column.

Treatment of patients with metastatic epidural spinal cord compression using an enhanced recovery after surgery program

Purpose: The aims of this study were to introduce a new medical, pathway based on the concept of "enhanced recovery after surgery" (ERAS) for patients with metastatic epidural spinal cord compression (MESCC), and to test whether the ERAS program could improve clinical metrics among such patients. Methods: Data from patients with MESCC (n = 98), collected between December 2016 and December 2019 (Non-ERAS cohort), and from 86 patients with metastatic epidural spinal cord compression collected between January 2020 and December 2022 (ERAS cohort), were retrospectively analyzed. Patients were treated by decompressive surgery combined with transpedicular screw implantation and internal fixation. Patient baseline clinical characteristics were collected and compared between the two cohorts. Surgical outcomes analyzed included operation time; intraoperative blood loss; postoperative length of hospital stay; time to ambulation, regular diet, urinary catheter removal, and radiation therapy; perioperative complications; anxiety; depression; and satisfaction with treatment. Results: No significant differences in clinical characteristics were found between the non-ERAS and enhanced recovery after surgery cohorts (all p > 0.050), indicating that the two cohorts were comparable. Regarding surgical outcomes, the enhanced recovery after surgery cohort had significantly less intraoperative blood loss (p < 0.001); shorter length of postoperative hospital stay (p < 0.001); shorter time to ambulation (p < 0.001), regular diet (p < 0.001), urinary catheter removal (p < 0.001), radiation administration (p < 0.001), and systemic internal therapy (p < 0.001); lower perioperative complication rate (p = 0.024); less postoperative anxiety (p = 0.041); and higher score for satisfaction with treatment (p < 0.001); whereas operation time (p = 0.524) and postoperative depression (p = 0.415) were similar between the two cohorts. Compliance analysis demonstrated that ERAS interventions were successfully conducted in the vast majority of patients. Conclusion: The enhanced recovery after surgery intervention is beneficial to patients with metastatic epidural spinal cord compression, according to data on intraoperative blood loss; length of hospital stay; time to ambulation, regular diet, urinary catheter removal, radiation exposure, and systemic internal therapy; perioperative complication; alleviation of anxiety; and improvement of satisfaction. However, clinical trials to investigate the effect of enhanced recovery after surgery are needed in the future.

The experiences and needs of metastatic spinal cancer family caregivers at home: a systematic review

PURPOSE

Family caregivers have high responsibilities for caring for persons with metastatic spinal cancer; however, understanding the experiences and needs of family caregivers face to overall recent, what is nurse-led could support them to meet their needs appropriately? Thus, the study aimed to review the experiences and needs of metastatic spinal cancer caregivers at home in the past decades.

METHODS

A qualitative systematic review of 8 studies was undertaken. Analysed studies were conducted in different countries (Australia, Cyprus, Italy, Kenya, Pakistan, Thailand, and Turkey), covering a population of 92 caregivers. Thematic analysis was applied to identify family caregiver experiences and needs.

RESULTS

Thematic analysis identified four key themes from the included studies: (1) complexity of needs, (2) caregivers' role and physical needs, (3) complexity of psychosocial needs, and (4) understanding supportive care.

CONCLUSIONS

The results across 8 different countries indicate that family caregivers of metastatic spinal cancer commonly face diverse challenges in many diverse geographical contexts across cultures, requiring biomedical, practical, physical, and psychosocial support from healthcare systems within the matrix of broader challenges and resources available to improve supportive care for such service users.

Stereotactic Body Radiation Therapy for Spinal Metastases: Benefits and Limitations

Progress in biological cancer characterization, targeted systemic therapies and multimodality treatment strategies have shifted the goals of radiotherapy for spinal metastases from short-term palliation to long-term symptom control and prevention of compilations. This article gives an overview of the spine stereotactic body radiotherapy (SBRT) methodology and clinical results of SBRT in cancer patients with painful vertebral metastases, metastatic spinal cord compression, oligometastatic disease and in a reirradiation situation. Outcomes after dose-intensified SBRT are compared with results of conventional radiotherapy and patient selection criteria will be discussed. Though rates of severe toxicity after spinal SBRT are low, strategies to minimize the risk of vertebral compression fracture, radiation induced myelopathy, plexopathy and myositis are summarized, to optimize the use of SBRT in multidisciplinary management of vertebral metastases.