Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

Prognostic Factors after Surgical Treatment for Spinal Metastases

STUDY DESIGN

A retrospective multicenter case series was conducted.

PURPOSE

This study aimed to investigate survival and prognostic factors after surgery for a metastatic spinal tumor.

OVERVIEW OF LITERATURE

Prognostic factors after spinal metastasis surgery remain controversial.

METHODS

A retrospective multicenter study was conducted. The study participants included 345 patients who underwent surgery for spinal metastases from 2010 to 2020 at nine referral spine centers in Japan. Data for each patient were extracted from medical records. To identify the factors predicting survival prognosis after surgery, univariate analyses were performed using a Cox proportional hazards model.

RESULTS

The mean age was 65.9 years. Common primary tumors were lung (n=72), prostate (n=61), and breast (n=39), and 67.8% (n=234) presented with osteolytic lesions. The epidural spinal cord compression scale score 2 or 3 was recognized in 79.0% (n=271). Frankel grade A paralysis accounted for 1.4% (n=5), and 73.3% (n=253) were categorized as intermediate or high risk according to the new Katagiri score. The overall survival rates were -71.0% at 6 months, 57.4% at 12, and 43.3% at 24. In the univariate analysis, Frankel grade A (hazard ratio [HR], 3.59; 95% confidence interval [CI], 1.23-10.50; p<0.05), intermediate risk (HR, 3.34; 95% CI, 2.10-5.32; p<0.01), and high risk (HR, 7.77; 95% CI, 4.72-12.8; p<0.01) in the new Katagiri score were significantly associated with poor survival. On the contrary, postoperative chemotherapy (HR, 0.23; 95% CI, 0.15-0.36; p<0.01), radiation therapy (HR, 0.43; 95% CI, 0.26-0.70; p<0.01), and both adjuvant therapy (HR, 0.21; 95% CI, 0.14-0.32; p<0.01) were suggested to improve survival.

CONCLUSIONS

Surgical indications for patients with Frankel grade A or intermediate or high risk in the new Katagiri score should be carefully considered because of poor survival. Chemotherapy or radiation therapy should be considered after surgery for better survival.

Application of the NSE score (Neurology-Stability-Epidural compression assessment) to establish the need for surgery in spinal metastases of elderly patients: a multicenter investigation

PURPOSE

This retropective multicentric study aims to investigate the clinical applicability of the NSE score in the elderly, to verify the role of this tool as an easy help for decision making also for this class of patients.

METHODS

All elderly patients (> 65 years) suffering from spinal metastases undergoing surgical or non-surgical treatment at the authors' Institutions between 2015 and 2022 were recruited. An agreement group (AG) and non-agreement group (NAG) were identified accordingly to the agreement between the NSE score indication and the performed treatment. Neurological status and axial pain were evaluated for both groups at follow-up (3 and 6 months). The same analysis was conducted specifically grouping patients older than 75 years.

RESULTS

A strong association with improvement or preservation of clinical status (p < 0.001) at follow-up was obtained in AG. The association was not statistically significant in NAG at the 3-month follow-up (p 1.00 and 0.07 respectively) and at 6 months (p 0.293 and 0.09 respectively). The group of patients over 75 years old showed similar results in terms of statistical association between the agreement group and better outcomes.

CONCLUSION

Far from the need or the aim to build dogmatic algorithms, the goal of preserving a proper performance status plays a key role in a modern oncological management: functional outcomes of the multicentric study group showed that the NSE score represents a reliable tool to establish the need for surgery also for elderly patients.

Implant and construct decision-making in metastatic spine tumour surgery: a review of current concepts with a decision-making algorithm

STUDY DESIGN

Narrative Review.

OBJECTIVE

Metastatic spine tumour surgery (MSTS) is an important treatment modality of metastatic spinal disease (MSD). Increase in MSTS has been due to improvements in our oncological treatment, as patients have increased longevity and even those with poorer comorbidities are now being considered for surgery. However, there is currently no guideline on how MSTS surgeons should select the appropriate levels to instrument, and which type of implants should be utilised.

METHODS

The current literature on MSTS was reviewed to study implant and construct decision making factors, with a view to write this narrative review. All studies that were related to instrumentation in MSTS were included.

RESULTS

A total of 58 studies were included in this review. We discuss novel decision-making models that should be taken into account when planning for surgery in patients undergoing MSTS. These factors include the quality of bone for instrumentation, the extent of the construct required for MSTS patients, the use of cement augmentation and the choice of implant. Various studies have advocated for the use of these modalities and demonstrated better outcomes in MSTS patients when used appropriately.

CONCLUSION

We have established a new instrumentation algorithm that should be taken into consideration for patients undergoing MSTS. It serves as an important guide for surgeons treating MSTS, with the continuous evolvement of our treatment capacity in MSD.

LEVEL OF EVIDENCE IV

Outcomes in Patients with Spinal Metastases Managed with Surgical Intervention

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and validation of a web-based artificial intelligence prediction model to assess massive intraoperative blood loss for metastatic spinal disease using machine learning techniques

BACKGROUND CONTEXT

Intraoperative blood loss is a significant concern in patients with metastatic spinal disease. Early identification of patients at high risk of experiencing massive intraoperative blood loss is crucial as it allows for the development of appropriate surgical plans and facilitates timely interventions. However, accurate prediction of intraoperative blood loss remains limited based on prior studies.

PURPOSE

The purpose of this study was to develop and validate a web-based artificial intelligence (AI) model to predict massive intraoperative blood loss during surgery for metastatic spinal disease.

STUDY DESIGN/SETTING

An observational cohort study.

PATIENT SAMPLE

Two hundred seventy-six patients with metastatic spinal tumors undergoing decompressive surgery from two hospitals were included for analysis. Of these, 200 patients were assigned to the derivation cohort for model development and internal validation, while the remaining 76 were allocated to the external validation cohort.

OUTCOME MEASURES

The primary outcome was massive intraoperative blood loss defined as an estimated blood loss of 2,500 cc or more.

METHODS

Data on patients' demographics, tumor conditions, oncological therapies, surgical strategies, and laboratory examinations were collected in the derivation cohort. SMOTETomek resampling (which is a combination of Synthetic Minority Oversampling Technique and Tomek Links Undersampling) was performed to balance the classes of the dataset and obtain an expanded dataset. The patients were randomly divided into two groups in a proportion of 7:3, with the most used for model development and the remaining for internal validation. External validation was performed in another cohort of 76 patients with metastatic spinal tumors undergoing decompressive surgery from a teaching hospital. The logistic regression (LR) model, and five machine learning models, including K-Nearest Neighbor (KNN), Decision Tree (DT), XGBoosting Machine (XGBM), Random Forest (RF), and Support Vector Machine (SVM), were used to develop prediction models. Model prediction performance was evaluated using area under the curve (AUC), recall, specificity, F1 score, Brier score, and log loss. A scoring system incorporating 10 evaluation metrics was developed to comprehensively evaluate the prediction performance.

RESULTS

The incidence of massive intraoperative blood loss was 23.50% (47/200). The model features were comprised of five clinical variables, including tumor type, smoking status, Eastern Cooperative Oncology Group (ECOG) score, surgical process, and preoperative platelet level. The XGBM model performed the best in AUC (0.857 [95% CI: 0.827, 0.877]), accuracy (0.771), recall (0.854), F1 score (0.787), Brier score (0.150), and log loss (0.461), and the RF model ranked second in AUC (0.826 [95% CI: 0.793, 0.861]) and precise (0.705), whereas the AUC of the LR model was only 0.710 (95% CI: 0.665, 0.771), the accuracy was 0.627, the recall was 0.610, and the F1 score was 0.617. According to the scoring system, the XGBM model obtained the highest total score of 55, which signifies the best predictive performance among the evaluated models. External validation showed that the AUC of the XGBM model was also up to 0.809 (95% CI: 0.778, 0.860) and the accuracy was 0.733. The XGBM model, was further deployed online, and can be freely accessed at https://starxueshu-massivebloodloss-main-iudy71.streamlit.app/.

CONCLUSIONS

The XGBM model may be a useful AI tool to assess the risk of intraoperative blood loss in patients with metastatic spinal disease undergoing decompressive surgery.

Reevaluating age restrictions of spinal metastasis surgery in elderly groups with over 2-year follow-up

This study aimed to compare and assess clinical outcomes of spinal metastasis with epidural spinal cord compression (MESCC) in patients aged 65-79 years and ≥ 80 years with an acute onset of neurological illness who underwent laminectomy. A second goal was to determine morbidity rates and potential risk factors for mortality. This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality were also collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). A total of 99 patients with an overall mean age of 76.2 ± 3.4 years diagnosed with MESCC within a 16-year period, of which 65 patients aged 65-79 years and 34 patients aged 80 years and older were enrolled in the study. Patients aged 80 and over had higher age-adjusted CCI (9.2 ± 2.1) compared to those aged 65-79 (5.1 ± 1.6; p < 0.001). Prostate cancer was the primary cause of spinal metastasis. Significant neurological and functional decline was more pronounced in the older group, evidenced by Karnofsky Performance Index (KPI) scores (80+ years: 47.8% ± 19.5; 65-79 years: 69.0% ± 23.9; p < 0.001). Despite requiring shorter decompression duration (148.8 ± 62.5 min vs. 199.4 ± 78.9 min; p = 0.004), the older group had more spinal levels needing decompression. Median survival time was 14.1 ± 4.3 months. Mortality risk factors included deteriorating functional status and comorbidities, but not motor weakness, surgical duration, extension of surgery, hospital or ICU stay, or complications. Overcoming age barriers in elderly surgical treatment in MSCC patients can reduce procedural delays and has the potential to significantly improve patient functionality. It emphasizes that age should not be a deterrent for spine surgery when medically necessary, although older MESCC patients may have reduced survival.

Outcomes and Complications of Surgery for Symptomatic Spinal Metastases; a Comparison Between Patients Aged ≥ 70 and <70

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Physicians may be deterred from operating on elderly patients due to fears of poorer outcomes and complications. We aimed to compare the outcomes of surgical treatment of spinal metastases patients aged ≥70-yrs and <70-yrs.

MATERIALS AND METHODS

This is a retrospective study of patients surgically treated for metastatic epidural spinal cord compression and spinal instability between January-2005 to December-2021. Follow-up was till death or minimum 1-year post-surgery. Outcomes included post-operative neurological status, ambulatory status, medical and surgical complications. Two Sample t-test/Mann Whitney U test were used for numerical variables and Pearson Chi-Squared or Fishers Exact test for categorical variables. Survival was presented with a Kaplan-Meier curve. P < .05 was significant.

RESULTS

We identified 412 patients of which 29 (7.1%) patients were excluded due to loss to follow-up and previous surgical treatment. 79 (20.6%) were ≥70-yrs. Age ≥70-yrs patients had poorer ECOG scores (P = .0017) and Charlson Comorbidity Index (P < .001). No significant difference in modified Tokuhashi score (P = .393) was observed with significantly more ≥ prostate (P < .001) and liver (P = .029) cancer in ≥70-yrs. Improved or maintained normal neurological function (P = .934), independent ambulatory status (P = .171), and survival at 6 months (P = .119) and 12 months (P = .659) was not significantly different between both groups. Medical (P = .528) or surgical (P = .466) complication rates and readmission rates (P = .800) were similar.

CONCLUSION

≥70-yrs patients have comparable outcomes to <70-yr old patients with no significant increase in complication rates. Age should not be a determining factor in deciding surgical management of spinal metastases.

Clinical Characteristics and Surgical Outcomes of Metastatic Spine Tumors in the Very Elderly: A Prospective Cohort Study in a Super-Aged Society

The number of advanced-age patients with spinal metastases is rising. This study was performed to clarify the characteristics and surgical outcomes of spinal metastases in advanced-age patients. We prospectively analyzed 216 patients with spinal metastases from 2015 to 2020 and divided them into three age groups: <70 years (n = 119), 70-79 years (n = 73), and ≥80 years (n = 24). Although there were no significant intergroup differences in preoperative characteristics and surgery-related factors except for age, patients aged ≥80 years tended to have a worse performance status (PS), Barthel index, and EuroQol-5 dimension (EQ-5D) before and after surgery than the other two groups. Although the median PS, mean Barthel index and mean EQ-5D greatly improved postoperatively in each group, the median PS and mean Barthel index at 6 months and the mean EQ-5D at 1 month postoperatively were significantly poorer in the ≥80-year group than the 70-79-year group. The rates of postoperative complications and re-deterioration of the EQ-5D were significantly higher in the oldest group than in the other two groups. Although surgery for spinal metastases improved the PS, Barthel index, and EQ-5D regardless of age, clinicians should be aware of the poorer outcomes and higher complication rates in advanced-age patients.

Emergency Posterior Decompression for Metastatic Spine Tumors in Octogenarians: Clinical Course and Prognostic Factors for Functional Outcomes

BACKGROUND

This study aimed to describe the clinical outcome of metastatic epidural spinal cord compression in octogenarians with an acute onset of neurological illness who undergo laminectomy, further assess morbidity and mortality rates, and determine potential risk factors for a nonambulatory outcome.

METHODS

This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected.

RESULTS

Thirty-four patients aged 80 years and older who posterior decompression via laminectomy were enrolled in the present study. The mean Charlson Comorbidity Index was >6 (9.2 ± 2.1). The thoracic spine was the most common site of metastasis. A potentially unstable spine, determined using the Spinal Instability Neoplastic Score, was identified in 79.4% of the cases. Preoperatively, the neurological condition and functional status exhibited a notable decline (mean Motor Score of the American Spinal Injury Association grading system, 78.2 ± 16.4; mean Karnofsky Performance Index, 47.8 ± 19.5). The Motor Score of the American Spinal Injury Association grading system and Karnofsky Performance Index scores improved significantly after surgery. Motor weakness and comorbidities were unique risk factors for the loss of ambulation.

CONCLUSIONS

Emergent decompressive laminectomy in patients with acute onset of neurological decline and potentially unstable spines improved functional outcome at discharge. Age should not be a determinant of whether to perform surgery; surgery should be performed in older patients when indicated.

Surgery for Metastatic Spinal Disease in Octogenarians and Above: Analysis of 78 Patients

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Octogenarians living with spinal metastases are a challenging population to treat. Our objective was to identify the rate, types, management, and predictors of complications and survival in octogenarians following surgery for spinal metastases.

METHODS

A retrospective review of a prospectively collected cohort of patients aged 80 years or older who underwent surgery for metastatic spinal tumor treatment between 2008 and 2019 were included. Demographic, intraoperative, complications, and postoperative follow-up data was collected. Cox proportional hazards regression and logistic regression were used to associate variables with overall survival and postoperative complications, respectively.

RESULTS

78 patients (mean 83.6 years) met inclusion criteria. Average operative time and blood loss were 157 minutes and 615 mL, respectively. The median length of stay was 7 days. The overall complication rate was 31% (N = 24), with 21% considered major and 7% considered life-threatening or fatal. Blood loss was significantly associated with postoperative complications (OR = 1.002; P = 0.02) and mortality (HR = 1.0007; P = 0.04). Significant associations of increased risk of death were also noted with surgeries with decompression, and cervical/cervicothoracic index level of disease. For deceased patients, median time to death was 4.5 months. For living patients, median follow-up was 14.5 months. The Kaplan-Meier based median overall survival for the cohort was 11.6 months (95% CI: 6.2-19.1).

CONCLUSIONS

In octogenarians undergoing surgery with instrumentation for spinal metastases, the median overall survival is 11.6 months. There is an increased complication rate, but only 7% are life-threatening or fatal. Patients are at increased risk for complications and mortality particularly when performing decompression with stabilization, with increasing intraoperative blood loss, and with cervical/cervicothoracic tumors.

A Discussion on the Criteria for Surgical Decision-Making in Elderly Patients With Metastatic Spinal Cord Compression

STUDY DESIGN

Retrospective study.

OBJECTIVES

Although the role of surgery in the management of metastatic spinal cord compression (MSCC) has been well established, elderly patients may still be denied surgery because of higher risk of complications and shorter life expectancy. The purpose of this study was to determine whether elderly patients with MSCC could benefit from surgery and discuss the criteria for surgical decision-making in such patients.

METHODS

Enrolled in this study were 55 consecutive patients aged 75 years or older who were surgically treated for MSCC in our center. Prognostic factors predicting overall survival (OS) were explored by the Kaplan-Meier method and Cox regression model. The quality of life (QoL) of the patients was evaluated by the SOSGOQ and compared using Student's t test. Risk factors for postoperative complications were identified by Chi-square test and multiple logistic regression analysis.

RESULTS

Surgical treatment for MSCC substantially improved the neurological function in 55.8% patients and QoL in 88.5% patients with acceptable rates of postoperative complications (16.4%), reoperation (9.1%), and 30-day mortality (1.8%). Postoperative ECOG-PS of 1-2, total en-bloc spondylectomy (TES), and postoperative chemotherapy were favorable prognostic factors for OS, while a high Charlson Comorbidity Index (CCI) and a long operation time were risk factors for postoperative complications.

CONCLUSIONS

Surgery should be encouraged for elderly patients with MSCC 1) who are compromised by the current or potential neurological dysfunction; 2) with radioresistant tumors; 3) with spinal instability; and 4) with no comorbidity, ECOG-PS of 0-2, and systemic treatment adherence. In addition, surgery should be performed by a skilled and experienced surgical team.

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

STUDY DESIGN

This was a case-control study.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What Is the Value of Undergoing Surgery for Spinal Metastases at Dedicated Cancer Centers?

BACKGROUND

The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases.

QUESTION/PURPOSE

Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals?

METHODS

The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs.

RESULTS

After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001).

CONCLUSION

Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Spine Metastasis in Elderly: Encouraging Results for Better Survival

MINI

The incidence of spinal metastasis (SpM) is increasing, and life expectancy for patients with malignancy is also rising. The "elderly" represent a population with steady growth in SpM proportion. Bracing is associated with lower survival. We believe that surgery should be considered, regardless of the patient's age.

Performance assessment of the metastatic spinal tumor frailty index using machine learning algorithms: limitations and future directions

OBJECTIVE

Frailty is recognized as an important consideration in patients with cancer who are undergoing therapies, including spine surgery. The definition of frailty in the context of spinal metastases is unclear, and few have studied such markers and their association with postoperative outcomes and survival. Using national databases, the metastatic spinal tumor frailty index (MSTFI) was developed as a tool to predict outcomes in this specific patient population and has not been tested with external data. The purpose of this study was to test the performance of the MSTFI with institutional data and determine whether machine learning methods could better identify measures of frailty as predictors of outcomes.

METHODS

Electronic health record data from 479 adult patients admitted to the Massachusetts General Hospital for metastatic spinal tumor surgery from 2010 to 2019 formed a validation cohort for the MSTFI to predict major complications, in-hospital mortality, and length of stay (LOS). The 9 parameters of the MSTFI were modeled in 3 machine learning algorithms (lasso regularization logistic regression, random forest, and gradient-boosted decision tree) to assess clinical outcome prediction and determine variable importance. Prediction performance of the models was measured by computing areas under the receiver operating characteristic curve (AUROCs), calibration, and confusion matrix metrics (positive predictive value, sensitivity, and specificity) and was subjected to internal bootstrap validation.

RESULTS

Of 479 patients (median age 64 years [IQR 55-71 years]; 58.7% male), 28.4% had complications after spine surgery. The in-hospital mortality rate was 1.9%, and the mean LOS was 7.8 days. The MSTFI demonstrated poor discrimination for predicting complications (AUROC 0.56, 95% CI 0.50-0.62) and in-hospital mortality (AUROC 0.69, 95% CI 0.54-0.85) in the validation cohort. For postoperative complications, machine learning approaches showed a greater advantage over the logistic regression model used to develop the MSTFI (AUROC 0.62, 95% CI 0.56-0.68 for random forest vs AUROC 0.56, 95% CI 0.50-0.62 for logistic regression). The random forest model had the highest positive predictive value (0.53, 95% CI 0.43-0.64) and the highest negative predictive value (0.77, 95% CI 0.72-0.81), with chronic lung disease, coagulopathy, anemia, and malnutrition identified as the most important predictors of postoperative complications.

CONCLUSIONS

This study highlights the challenges of defining and quantifying frailty in the metastatic spine tumor population. Further study is required to improve the determination of surgical frailty in this specific cohort.

Predicting postoperative quality-of-life outcomes in patients with metastatic spine disease: who benefits?

Symptomatic spinal metastasis occurs in around 10% of all cancer patients, 5%-10% of whom will require operative management. While postoperative survival has been extensively evaluated, postoperative health-related quality-of-life (HRQOL) outcomes have remained relatively understudied. Available tools that measure HRQOL are heterogeneous and may emphasize different aspects of HRQOL. The authors of this paper recommend the use of the EQ-5D and Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ), given their extensive validation, to capture the QOL effects of systemic disease and spine metastases. Recent studies have identified preoperative QOL, baseline functional status, and neurological function as potential predictors of postoperative QOL outcomes, but heterogeneity across studies limits the ability to derive meaningful conclusions from the data. Future development of a valid and reliable prognostic model will likely require the application of a standardized protocol in the context of a multicenter study design.

A Novel Clinical Scoring System for Perioperative Morbidity in Metastatic Spinal Tumor Surgery: The Spine Oncology Morbidity Assessment Score

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate a scoring system to predict morbidity for patients undergoing metastatic spinal tumor surgery (MSTS).

SUMMARY OF BACKGROUND DATA

Multiple scoring systems exist to predict survival for patients with spinal metastasis. The potential benefits and risks of surgery need to be evaluated for patients with disseminated cancer and limited life expectancy. Few scoring systems exist to predict perioperative morbidity after MSTS.

METHODS

We reviewed records of patients who underwent MSTS at our institution between 2013 and 2019. All perioperative complications occurring within 30 days were recorded. A clinical scoring system consisting of five variables (age ≥ 70 yr, hypoalbuminemia, poor preoperative functional status [Karnofsky ≤ 40], Frankel Grade A-C, and multilevel disease ≥2 continuous vertebral bodies) was evaluated as a predictive tool for morbidity; every parameter was assigned a value of 0 if absent or 1 if present (total possible score = 5). The effect of the scoring system on morbidity was evaluated using stepwise multiple logistic regression. Model accuracy was calculated by receiver operating characteristic analysis.

RESULTS

One hundred and five patients were identified, with a male prevalence of 58.1% and average age at surgery of 61 years. The overall 30-day complication rate was 36.2%. The perioperative morbidity was 4.6%, 30.0%, 53.9%, and 64.7% for patients with scores of 0, 1, 2, and ≥3 points, respectively (P < 0.001). On multiple logistic regression analysis controlling for covariates not present in the model, the scoring system was significantly associated with 30-day morbidity (OR 3.11; 95% CI, 1.72-5.59; P < 0.001). The model's accuracy was estimated at 0.75.

CONCLUSION

Our proposed model was found to accurately predict perioperative morbidity after MSTS. The Spine Oncology Morbidity Assessment (SOMA) score may prove useful for risk stratification and possibly decision-making, though further validation is needed.Level of Evidence: 4.

Prospective cohort study of surgical outcome for spinal metastases in patients aged 70 years or older

AIMS

With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values.

METHODS

We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected.

RESULTS

In total, 65 patients were aged < 70 years (mean 59.6 years; 32 to 69) and 36 patients were aged ≥ 70 years (mean 75.9 years; 70 to 90). In both groups, the PS improved from PS3 to PS1 by spine surgery, the mean BI improved from < 60 to > 80 points, and the mean EQ-5D score improved from 0.0 to > 0.7 points. However, no significant differences were found in the improvement rates and values of the PS, BI, and EQ-5D score at any time points between the two groups. The PS, BI, and EQ-5D score improved throughout the follow-up period in approximately 90% of patients in each group. However, the improved PS, BI, and EQ-5D scores subsequently deteriorated in some patients, and the redeterioration rate of the EQ-5D was significantly higher in patients aged ≥ 70 than < 70 years (p = 0.027).

CONCLUSION

Palliative surgery for spinal metastases improved the PS, activities of daily living, and quality of life, regardless of age. However, clinicians should be aware of the higher risk of redeterioration of the quality of life in advanced-age patients. Cite this article: Bone Joint J 2020;102-B(12):1709-1716.

Influence of preoperative biological parameters on postoperative complications and survival in spinal bone metastasis. A multicenter prospective study

INTRODUCTION

Onset of spinal bone metastasis is a turning point in the progression of tumoral disease; although incidence is increasing, management is not standardized. Various prognostic scores are available, but advances in medical and surgical treatment have made them less well adapted, and sometimes discordant for a given patient. It would therefore be useful to develop new prognostic instruments. The aim of the present study was to identify biologic risk factors for onset of postoperative complications and death following spinal bone metastasis surgery.

MATERIAL AND METHODS

A prospective multicenter study included all patients operated on for spinal bone metastasis between November 2015 and May 2017. The main epidemiologic data and biologic data (CRP, albuminemia, calcemia) were collected preoperatively. Surgical strategy, death and/or postoperative complications were collected prospectively.

RESULTS

Five of the initial 264 patients died during the immediate postoperative course, and 107 within 6 months. At 1 year, 57 patients remained alive. Twenty-six (10%) were lost to follow-up. Preoperative albuminemia<35g/L (29% of patients), calcemia>2.6 nmol/L (8%) and CRP>10mg/L (47.5%) were associated with significantly elevated mortality. Only CRP elevation correlated with postoperative complications rate.

CONCLUSION

The study confirmed the prognostic value of 3 biologic parameters (CRP level, albuminemia, calcemia) for survival after spinal bone metastasis surgery. A hybrid score taking account of not only clinical but also biologic parameters should be developed to improve estimation of survival.

Necessity of Bony Fusion After Surgical Treatment of Metastatic Spine Tumors

INTRODUCTION

The role of bony fusion in influencing patient outcome and surgical revision rates in the treatment of metastatic spine disease is poorly defined. The goals of this study were, therefore, to evaluate the effect of fusion on revision surgery as well as on overall survival (OS) and functional status in patients with metastatic disease of the spine.

METHODS

A retrospective cohort study of a prospective database at a major cancer center was conducted. A total of 25 patients who met the inclusion criteria from January 2010 to December 2015 were included. Functional status, patient and tumor characteristics, fusion status, and survival were analyzed, and regression analyses were done. Bony fusion was classified as either present (seen across a minimum of three levels and crossing the tumor site) or absent as evidenced through CT images at minimum of 1-year postoperatively.

RESULTS

Twenty-five subjects with 28 surgical sites met the eligibility criteria to be included in this study cohort. Five surgical sites were found to have evidence of fusion on CT scans at 1 year after surgery, and 23 sites had no evidence of bridging fusion. No differences were found between the two groups in terms of OS, and ambulatory status (P > 0.10). Multivariate analysis did not reveal any specific factors affecting fusion. Mean follow-up was 23.7 months.

DISCUSSION

The lack of bony fusion is not an independent predictor of the need for revision surgery. The lack of bony fusion in patients with metastatic disease of the spine does not appear to negatively affect their OS or their ambulatory status. A discussion of factors affecting fusion is complex, and there are other factors that may also play a role. Large multicenter trials are needed to corroborate the preliminary findings seen in this complex patient cohort.

Value of aggressive surgical and intensive care unit in elderly patients with traumatic spinal cord injury

OBJECTIVEThe elderly are a growing subpopulation within traumatic spinal cord injury (SCI) patients. Studies have reported high morbidity and mortality rates in elderly patients who undergo surgery for SCI. In this study, the authors compare the perioperative outcomes of surgically managed elderly SCI patients with those of a younger cohort and those reported in the literature.METHODSData on a consecutive series of adult traumatic SCI patients surgically managed at a single institution in the period from 2007 to 2017 were retrospectively reviewed. The cohort was divided into two groups based on age: younger than 70 years and 70 years or older. Assessed outcomes included complications, in-hospital mortality, intensive care unit (ICU) stay, hospital length of stay (LOS), disposition, and neurological status.RESULTSA total of 106 patients were included in the study: 83 young and 23 elderly. The two groups were similar in terms of imaging features (cord hemorrhage and fracture), operative technique, and American Spinal Injury Association Impairment Scale (AIS) grade. The elderly had a significantly higher proportion of cervical SCIs (95.7% vs 71.1%, p = 0.047). There were no significant differences between the young and the elderly in terms of the ICU stay (13.1 vs 13.3 days, respectively, p = 0.948) and hospital LOS (23.3 vs 21.7 days, p = 0.793). Elderly patients experienced significantly higher complication (73.9% vs 43.4%, p = 0.010) and mortality (13.0% vs 1.2%, p = 0.008) rates; in other words, the elderly patients had 1.7 times and 10.8 times the rate of complications and mortality, respectively, than the younger patients. No elderly patients were discharged home (0.0% vs 18.1%, p = 0.029). Discharge AIS grade and AIS grade change were similar between the groups.CONCLUSIONSElderly patients had higher complication and mortality rates than those in younger patients and were less likely to be discharged home. However, it does seem that mortality rates have improved compared to those in prior historical reports.

Vertebrectomy in metastatic spinal tumours: A 10 year, single-centre review of outcomes and survival

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.

High Risk of Symptomatic Venous Thromboembolism After Surgery for Spine Metastatic Bone Lesions: A Retrospective Study

BACKGROUND

Cancer and spinal surgery are both considered risk factors for venous thromboembolism (VTE). However, the risk of symptomatic VTE for patients undergoing surgery for spine metastases remains undefined.

QUESTIONS/PURPOSES

The purposes of this study were to: (1) identify the proportion of patients who develop symptomatic VTE within 90-days of surgical treatment for spine metastases; (2) identify the factors associated with the development of symptomatic VTE among patients receiving surgery for spine metastases; (3) assess the association between the development of postoperative symptomatic VTE and 1-year survival among patients who underwent surgery for spine metastases; and (4) assess if chemoprophylaxis increases the risk of wound complications among patients who underwent surgery for spine metastases.

METHODS

Between 2002 and 2014, 637 patients at two hospitals underwent spine surgery for metastases. We considered eligible for analysis adult patients whose procedures were to treat cervical, thoracic, or lumbar metastases (including lymphoma and multiple myeloma). At followup after 90 days and 1 year, respectively, 21 of 637 patients (3%) and 41 of 637 patients (6%) were lost to followup. In general, we used 40 mg of enoxaparin or 5000 IUs subcutaneous heparin every 12 hours. Patients on preoperative chemoprophylaxis continued their initial medication postoperatively. All chemoprophylaxis was started 48 hours after surgery and continued day to day but was discontinued if a bleeding complication developed. Low-molecular-weight heparin (including enoxaparin and dalteparin, in general dosages of respectively 40 mg and 5000 IUs daily) was the most commonly used chemoprophylaxis in 308 patients (48%). Subcutaneous heparin was injected into 127 patients (20%); aspirin was used for 92 patients (14%); and warfarin was administered in 21 patients (3.3%). No form of chemoprophylaxis was prescribed for 89 patients (14%). The primary outcome variable, VTE, was defined as any symptomatic pulmonary embolism (PE) or symptomatic deep venous thromboembolism (DVT) within 90 days of surgery as determined by chart review. The secondary outcome was defined as any documented wound complication within 90 days of surgery that might be attributable to chemoprophylaxis. Statistical analysis was performed using multivariable logistic and Cox regression and Kaplan-Meier.

RESULTS

Overall, 72 of 637 patients (11%) had symptomatic VTE; 38 (6%) developed a PE-eight (1.3%) of which were fatal-and 40 (6%) a DVT. After controlling for relevant confounding variables such as age, the modified Charlson Comorbidity Index, visceral metastases, and chemoprophylaxis, longer duration of surgery was independently associated with an increased risk of symptomatic VTE (odds ratio 1.15 for each additional hour of surgery; 95% confidence interval [CI], 1.04-1.28; p = 0.009). After controlling for relevant confounding variables such as age, the modified Charlson Comorbidity Index, visceral metastases, and primary tumor type, patients with symptomatic VTE had a worse 1-year survival rate (VTE, 38%; 95% CI, 27-49 versus nonVTE, 47%; 95% CI, 42-51; p = 0.044). After controlling for relevant confounding variables, no association was found between wound complications and the use of chemoprophylaxis (odds ratio, 1.34; 95% CI, 0.62-2.90; p = 0.459). The overall proportion of patients who developed a wound complication was 10% (66 of 637), including 1.1% (seven of 637) spinal epidural hematomas.

CONCLUSIONS

The risk of both symptomatic PE and fatal PE is high in this patient population, and those with symptomatic VTE were less likely to survive 1-year than those who did not, though this may reflect overall infirmity as much as anything else, because many of these patients did not die from VTE-related complications. Further study, such as randomized controlled trials with consistent postoperative VTE screening comparing different chemoprophylaxis regimens, are needed to identify better VTE prevention strategies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Treatment, complications, and outcomes of metastatic disease of the spine: from Patchell to PROMIS

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.

Morphometrical evaluation of decompression obtained through corpectomy. Heading towards to posterior approaches

INTRODUCTION

We analysed the decompression obtained by dorsal or dorsolumbar corpectomy measured by Cobb angle and the spinal area prior to and after surgery and compared the evolution of the technique over the last five years of the study.

MATERIAL AND METHOD

A retrospective review of patients operated between 2005 and 2015 through anterior or posterior approaches was performed.

RESULTS

24 patients were studied and a significant improvement was observed between the preoperative and postoperative morphometrical measurement (4.18° correction of the kyphosis and an increase of 130.8mm² in the spinal canal, p<.001 in both cases) and in clinical parameters (45.8% of patients improved in ASIA, and Karnofsky showed 13 points of improvement, p<.001 in both cases). However, there was no correlation between clinical and morphological parameters. We also observed that in the last five years of the study posterior approaches were more frequently used with good results.

CONCLUSIONS

Dorsal corpectomy allows significant spinal decompression, with neurological improvement but this does not correlate with the measurement of decompression. Thanks to technical improvements, less invasive techniques (posterior approaches and MISS) allow good clinical results, which are similar to those obtained by anterior techniques.

Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression

BACKGROUND AND CONTEXT

Metastatic epidural spinal cord compression (MESCC) is a disabling consequence of disease progression. Surgery can restore or preserve physical function, improving access to treatments that increase duration of survival; however, advanced patient age may deter oncologists and surgeons from considering surgical management.

PURPOSE

Evaluate the duration of ambulation and survival in elderly patients following surgical decompression of MESCC.

STUDY DESIGN/SETTING

Retrospective file review of a prospective database, under institutional review board (IRB) waiver of informed consent, of consecutive patients treated in an academic tertiary care medical center from August 2008 to March 2015.

PATIENT SAMPLE

Patients ≥65 years presenting neurological and/or radiological signs of cord compression because of metastatic disease, who underwent surgical decompression.

OUTCOME MEASURES

Duration of ambulation and survival.

METHODS

Patients underwent urgent multidisciplinary evaluation and surgery. Ambulation and survival were compared with age, pre-, and postoperative neurological (American Spinal Injury Association [ASIA] Impairment Scale [AIS]) and performance status (Karnofsky Performance Status [KPS]), and Tokuhashi Score using Kruskal-Wallis and Wilcoxon signed rank tests, Pearson correlation coefficient, Cox regression model, log-rank analysis, and Kaplan-Meier analysis.

RESULTS

Forty patients were included (21 male, 54%; mean age 74 years, range 65-87). Surgery was performed a mean 3.8 days after onset of motor symptoms. Mean duration of ambulation and survival were 474 (range 0-1662) and 525 days (range 11-1662), respectively; 53% of patients (21 of 40) survived and 43% (17 of 40) retained ambulation for ≥1 year. There was no significant relationship between survival and ambulation for patients aged 65-69, 70-79, or 80-89 years, although Kaplan-Meier analysis suggested stratification. There was a significant relationship between duration of ambulation and pre- and postoperative AIS (p=.0342, p=.0358, respectively) and postoperative KPS (p=.0221). Tokuhashi score was not significantly related to duration of survival or ambulation, and greatly underestimated life expectancy in 22 of 37 (59%) patients with scores 0-11.

CONCLUSIONS

Decompressive surgery led to marked improvement in neurological function and performance status. More than 50% of patients survived for >1 year, some for 3 years or more after surgery.

Survival Outcomes and Factors Associated with Revision Surgery for Metastatic Disease of the Spine

Study Design

Retrospective review of a prospective database.

Objective

Certain subset of patients undergoing surgical treatment for spinal metastasis will require a revision surgery in their disease course; however, factors predictive of revision surgery and survival outcomes are largely unknown. The goal of this study is to report on survival outcomes as well as factors predictive of revision surgery in this unique patient population.

Methods

A total of 55 patients who met the inclusion criteria were included from January 2010 to December 2015. Twelve (22%) of these patients underwent a revision surgery. Patient and tumor characteristics were summarized and survival outcomes were evaluated using Kaplan-Meier methods and Cox proportional hazards regression.

Results

Both the revision and the nonrevision groups were similarly matched with respect to spine disease burden, neurological status at time of initial presentation, primary malignancy types, and the use of adjuvant treatment modalities. Tumor progression (66.7%) was the most common reason for necessitating a revision followed by nonunion (16.7%), wound dehiscence (8.3%), and construct failure (8.3%). Following multivariate model selection procedures, smokers were found to have 3.5 times increased odds of undergoing revision compared to nonsmokers (p = 0.05). Analysis of survival curves showed that the median survival in the revision group was 3.0 years (95% CI: 1.5, 4.1), while the median survival in the nonrevision group was 1.5 years (95% CI: 1.1, 2.3; log-rank test, p = 0.105).

Conclusion

Despite aggressive treatment, tumor progression is the most common reason for revision surgery. Smoking is an independent risk factor for revision. Revision surgery should be considered in patients when indicated as it does not appear to detrimentally affect survival.

Cervical vertebroplasty for osteolytic metastases as a minimally invasive therapeutic option in oncological surgery: outcome in 14 cases

OBJECTIVE The treatment of cervical spinal metastases represents a controversial issue regarding the type, extent, and invasiveness of interventions. In the lumbar and thoracic spine, kypho- and vertebroplasties have been established as minimally invasive procedures for patients with metastases to the vertebral bodies and without neurological deficit. These procedures show good results with respect to pain reduction and low complication rates. However, limited data are available for kypho- and vertebroplasties for cervical spinal metastases. In an effort to add to existing data, the authors here present a case series of 14 patients who were treated for osteolytic metastases of the cervical spine using vertebroplasty alone or in addition to another surgical procedure involving the cervical spine in a palliative setting to reduce pain and restore stability. METHODS Fourteen patients consisting of 8 males and 6 females, with a mean age of 64.7 years (range 44-85 years), were treated with vertebroplasty at the authors' clinic between January 2015 and November 2016. In total, 25 vertebrae were treated with vertebroplasty: 10 C-2, 5 C-3, 2 C-4, 2 C-5, 3 C-6, and 3 C-7. Two patients had an additional posterior stabilization and 5 patients an additional anterior stabilization. In 13 cases, the surgical approach was a modified Smith-Robinson approach; in 1 case, the cement was injected into the corpus axis from posteriorly. Patients with osteolytic defects of the posterior wall of the vertebral body did not undergo surgery, nor did patients with neurological deficits. Preoperatively, on the 2nd day after surgery, and at the follow-up, neck pain was rated using the visual analog scale (VAS). RESULTS Twelve patients were examined at follow-up (mean 9 months). Neck pain was rated as a mean of 6.0 (range 3-8) preoperatively, 2.9 on Day 2 after surgery (range 0-5), and 0.5 at the follow-up (range 0-4), according to the VAS. The mean Neck Disability Index at follow-up was 3.6% (range 0%-18%). CONCLUSIONS Anterior vertebroplasty of the cervical spine via an anterolateral approach represents a safe and minimally invasive procedure with a low complication rate and appears suitable for reducing pain and restoring stability in cases of cervical spinal metastases. Vertebroplasties can be combined with other anterior and posterior operations of the cervical spine and, in the axis vertebra, can be performed transpedicularly from posteriorly. Thus, in cases in which the posterior wall of the vertebral body is intact, vertebroplasty represents a less invasive alternative to vertebral replacement in oncological surgery. Prospective randomized trials with a longer follow-up period and a larger patient cohort are needed to confirm the encouraging results of this case series.

The relationship of older age and perioperative outcomes following thoracolumbar three-column osteotomy for adult spinal deformity: an analysis of 300 consecutive cases

OBJECTIVE Three-column osteotomies are increasingly being used in the elderly population to correct rigid spinal deformities. There is hesitation, however, in performing the technique in older patients because of the high risk for blood loss, longer operative times, and complications. This study assesses whether age alone is an independent risk factor for complications and length of stay. METHODS All patients with thoracolumbar adult spinal deformity (ASD) who underwent 3-column osteotomy (vertebral column resection or pedicle subtraction osteotomy) performed by the senior author from 2006 to 2016 were identified. Demographics, clinical baseline, and surgical details were collected. Outcomes of interest included perioperative complication, ICU stay, and hospital stay. Bivariate and multivariate analyses were used to assess the association of age with outcomes of interest. RESULTS A total of 300 patients were included, and 38.3% were male. The mean age was 63.7 years: 10.3% of patients were younger than 50 years, 36.0% were 50-64 years, 45.7% were 65-79 years, and 8.0% were 80 years or older. The overall mean EBL was 1999 ml. The overall perioperative complication rate was 24.7%: 18.0% had a medical complication and 7.0% had a surgical complication. There were no perioperative or 30-day deaths. Age was associated with overall complications (p = 0.002) and medical-specific complications (p < 0.001); there were higher rates of overall and medical complications with increased age: 9.7% and 6.5%, respectively, for patients younger than 50 years; 16.7% and 10.2%, respectively, for patients 50-64 years; 31.4% and 22.6%, respectively, for patients 65-79 years; and 41.7% and 41.7%, respectively, for patients 80 years or older. However, after adjusting for relevant covariates on multivariate analysis, age was not an independent factor for perioperative complications. Surgical complication rates were similar among the 4 age groups. Longer ICU and total hospital stays were observed in older age groups, and age was an independent factor associated with longer ICU stay (p = 0.028) and total hospital stay (p = 0.003). ICU stays among the 4 age groups were 1.6, 2.3, 2.0, and 3.2 days for patients younger than 50 years, 50-64 years, 65-79 years, and 80 years or older, respectively. The total hospital stays stratified by age were 7.3, 7.7, 8.2, and 11.0 days for patients younger than 50 years, 50-64 years, 65-79 years, and 80 years or older, respectively. CONCLUSIONS Older age was associated with higher perioperative complication rates, but age alone was not an independent risk factor for complications following the 3-column osteotomy for ASD. Comorbidities and other unknown variables that come with age are likely what put these patients at higher risk for complications. Older age, however, is independently associated with longer ICU and hospital stays.

Minimally Invasive Separation Surgery with Intraoperative Stereotactic Guidance: A Feasibility Study

BACKGROUND

The treatment of spinal metastasis consists of algorithms combining surgical and radiation modalities. Recently the concept of separation surgery followed by stereotactic radiosurgery was shown to be a safe and effective treatment to achieve local tumor control.

OBJECTIVE

We examined a minimally invasive approach to separation surgery in a cadaveric study followed by a patient cohort with spinal metastasis using navigation to discuss our results and provide a technical note.

METHODS

A cadaveric study using minimally invasive access systems examined the feasibility of spinal cord decompression. Subsequently, 17 patients with spinal metastasis underwent minimally invasive separation surgery and instrumentation using navigation. All patients were at least 3/5 and pre- and post-operative CT scans were used to evaluate the decompression. Endpoints included neurologic function, operative time, estimated blood loss, duration of hospital stay, and complications.

RESULTS

The cadaveric study demonstrated adequate decompression of the spinal cord. For the operative cases, the post-operative imaging demonstrated excellent separation for safe stereotactic radiosurgery. The mean incision length was 4.9 cm. The average operative time was 6 hours and 48 minutes, the mean length of stay was 12.8 days and the mean surgical blood loss was 458 mL. The median Spine Instability Neoplastic Score score was 10 with a range of 6-16. All patients remained or improved their neurologic baseline with excellent pain control. One patient incurred a perioperative complication.

CONCLUSIONS

Minimally invasive separation surgery for spinal metastasis allows for circumferential decompression of the spinal cord and safe post-operative stereotactic radiosurgery. In addition, we demonstrated the efficacy of intra-operative navigation in guiding the resection.

Safety of Immediate Posterior Trunk Soft-Tissue Reconstruction in Older Adults

Background:

Older patients, especially those older than 65 years, are accounting for an ever-increasing share of hospital costs, especially surgical procedures. Studies regarding the safety of surgery in these patients have been widespread in the past decade. Despite these efforts, there is a paucity of information regarding the safety of reconstruction following spinal surgery in older patients.

Methods:

We conducted a retrospective cohort study of patients undergoing soft-tissue reconstruction of the posterior trunk after oncologic spine surgery. Demographic, medical, and surgical variables were measured. The primary outcome variable was the development of a medical or surgical complication postoperatively. Other secondary outcomes included development of a medical complication alone, specific surgical complications (seroma, hematoma, infection, wound dehiscence, and (cerebrospinal fluid leak), unplanned reoperation, and 60-day operative mortality.

Results:

A priori power analysis suggested 205 cases would be needed. The study included 286 cases in 256 patients. The cohorts were similar in terms of demographic, surgical, and medical variables, though the older cohort had higher mean American Society of Anesthesiologists score (2.09 versus 1.65; P < 0.0001). We found no correlation between increasing age and increased rates of medical or surgical complications (35.9% for older patients versus 44.7% for younger patients; P = 0.31). However, mean American Society of Anesthesiologists score did correlate with complications (1.88 for patients with complications versus 1.69 for patients without; P = 0.04).

Conclusions:

We demonstrated no increased risk for complications among older patients. Complex soft-tissue reconstruction of the posterior trunk is safe in elderly patients undergoing oncologic spinal surgery.

Percutaneous sacroplasty for the management of painful pathologic fracture in a multiple myeloma patient: Case report and review of the literature

Percutaneous kyphoplasty has a well-established role in the treatment of pathologic fractures in patients with multiple myeloma. Despite this, there is a scarcity of literature surrounding its use and efficacy in the sacrum. We present a case of successful symptom resolution in a patient with painful sacral fracture following sacroplasty, and review the existing literature. An 81-year-man with multiple myeloma presented to the hematology/oncology clinic with a history of excruciating pain while seated. The impact of this pain on his quality of life subjectively was rated to be particularly high. Computed tomography of the sacrum confirmed the presence of pathologic fracture within the S1 and S2 vertebrae. Under fluoroscopic guidance, polymethyl methacrylate (PMMA) bone cement was injected via 11-gauge needles using an anterior-oblique approach. No immediate post-procedural complications occurred, such as foraminal extravasation or venous injection. The patient reported himself to be pain-free 1 day following the procedure, and this remains the case to date at 2 years of follow-up. Sacroplasty is technically feasible and can provide durable relief of symptoms in patients with painful pathologic fractures of the sacrum. It is likely underused and can offer tremendous benefit to myeloma patients.