A Natural History of Patients Treated Operatively and Nonoperatively for Spinal Metastases Over 2 Years Following Treatment: Survival and Functional Outcomes

The role of combination surgery and radiotherapy in patients with metastatic spinal cord compression: What are the remaining grey areas? A systematic review

OBJECTIVE

Traditional management of patients with metastatic epidural spinal cord compression (MESCC) consists of radiotherapy (RT) with or without surgical decompression. With extensive literature and the introduction of clinical frameworks, such as the neurologic, oncologic, mechanical, and systemic criteria and the epidural spinal cord compression scale, progress has been made in refining the appropriate treatment regimen. In this review, we analyze the existing literature to identify the consensus frameworks and the remaining gaps in clinical knowledge.

METHODS

PubMed, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov were queried in January 2023. Only articles comparing combination therapy (surgery plus RT) to RT alone and assessing neurological and/or survival outcomes in patients with MESCC were retained for full-text review.

RESULTS

Out of 2157 unique articles, 29 met inclusion criteria. The most common primary cancer locations included lung (n=1031, 20.0 %), breast (n=747, 14.5 %), and prostate (n=712, 13.8 %), and back pain was the most common symptom reported (n=1186/1622, 73.1 %). While baseline patient characteristics were not controlled between the different treatment regimens, the included studies demonstrated a median survival of 4.0 months (interquartile range [IQR] 3.0-6.1 months) in patients receiving RT alone compared to 7.7 months (IQR 6.3-11.1 months) in the cohort receiving combination therapy. Similarly, in patients undergoing RT alone, a median of 29.0 % (IQR 16.0-37.9 %) of patients experienced a neurologic improvement, compared to 38.0 % (IQR 31.5-64.4 %) of patients undergoing combination therapy.

CONCLUSIONS

In patients with high-grade, symptomatic MESCC, combination therapy with direct circumferential decompression is superior to RT alone in patients with less radiosensitive tumors. In patients with high-grade asymptomatic MESCC, RT alone can be pursued for patients with the most radiosensitive tumors, such as myeloma and lymphoma; however, more research is needed on the treatment of less radiosensitive tumors. A major grey area exists in the treatment of patients with intermediate grade epidural involvement.

Neuro-oncologic Emergencies

OBJECTIVE

Neuro-oncologic emergencies have become more frequent as cancer remains one of the leading causes of death in the United States, second only to heart disease. This article highlights key aspects of epidemiology, diagnosis, and management of acute neurologic complications in primary central nervous system malignancies and systemic cancer, following three thematic classifications: (1) complications that are anatomically or intrinsically tumor-related, (2) complications that are tumor-mediated, and (3) complications that are treatment-related.

LATEST DEVELOPMENTS

The main driver of mortality in patients with brain metastasis is systemic disease progression; however, intracranial hypertension, treatment-resistant seizures, and overall decline due to increased intracranial burden of disease are the main factors underlying neurologic-related deaths. Advances in the understanding of tumor-specific characteristics can better inform risk stratification of neurologic complications. Following standardized grading and management algorithms for neurotoxic syndromes related to newer immunologic therapies is paramount to achieving favorable outcomes.

ESSENTIAL POINTS

Neuro-oncologic emergencies span the boundaries of subspecialties in neurology and require a broad understanding of neuroimmunology, neuronal hyperexcitability, CSF flow dynamics, intracranial compliance, and neuroanatomy.

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.

Risk Factors for Postoperative Unfavorable Ambulatory Status After Spinal Surgery for Metastatic Spinal Tumor

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

This study aimed to investigate factors associated with postoperative unfavorable ambulatory status following surgery for metastatic spinal tumors using a nationwide in-hospital database.

SUMMARY OF BACKGROUND DATA

Surgical treatment for metastatic spinal tumors can improve the ambulatory status and quality of life. However, some patients fail to regain the ability to walk, thereby resulting in poor quality of life. No large-scale study has previously evaluated factors associated with postoperative poor ambulatory status in this clinical context.

MATERIALS AND METHODS

The Diagnosis Procedure Combination database from 2018 to 2019 was used to extract data from patients who underwent surgical procedures for spinal metastasis. Postoperative unfavorable ambulatory status was defined as (1) nonambulatory at discharge or (2) a decreased mobility score of the Barthel Index between admission and discharge. Multivariable logistic regression was used to evaluate factors associated with postoperative unfavorable ambulatory status while adjusting for confounders.

RESULTS

This study analyzed 1786 eligible patients. Of whom, 1061 (59%) patients were ambulatory on admission and 1249 (70%) on discharge. Postoperative unfavorable ambulatory status was observed in 597 (33%) patients, with a significantly lower rate of discharge to home (41%/81%, P <0.001) and a longer postoperative hospital stay (46.2 days/31.4 days, P <0.001). Multivariable regression analysis revealed male sex [odds ratio (OR): 1.43, P =0.002], laminectomy without fusion (OR: 1.55, P =0.034), Charlson Comorbidity Index of ≥7 (OR: 1.37, P =0.014), and preoperative nonambulatory status (OR: 6.61, P <0.001) as factors associated with postoperative unfavorable ambulatory status.

CONCLUSIONS

Our large-scale database analysis revealed that 33% of patients experienced unfavorable ambulatory status following spinal metastasis surgery. Laminectomy without fusion and preoperative nonambulatory status were among several factors influencing the prospect of unfavorable ambulatory status following surgery.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Prognostic factors and outcomes of surgical intervention for patients with spinal metastases secondary to lung cancer: an update systematic review and meta analysis

PURPOSE

Lung cancer is one of the most common malignant tumors. Most patients develop spinal metastases during the course of cancer and suffer skeletal-related events. Currently, no consensus has been reached on the prognostic factors in patients undergoing surgeries. This study aimed to answer two questions: (1) what are the effects of surgical intervention, and (2) what are the factors associated with postoperative survival.

METHODS

Searches were performed on electronic databases including PubMed, Ovid/MEDLINE, Cochrane, and Scopus for articles published before February of 2022, involving the survival factors of patients with spinal metastasis. Multiple data items were considered, such as baseline demographics, surgical details, clinical outcome, and prognostic factors. The analysis was performed in Review Manager (RevMan) 5.5. The prognostic factors of survival were analyzed with univariate and multivariate cox regression analysis.

RESULTS

Finally, 14 studies with 813 patients were identified. Their 6, 12, and 24 months survival rates ranged from 18 to 58%, 18 to 22.4%, and 0 to 58.5%, respectively. The pooled hazard ratio of preoperative ambulatory status and the number of involved vertebrae demonstrated statistical significance, while no significant prognostic effect on the overall survival was found for targeted therapy, visceral metastases, chemotherapy, radiotherapy, or postoperative ambulatory status.

CONCLUSION

Overall, surgical intervention could achieve significant pain relief and neurological function improvements. For patients receiving surgery for spinal metastasis from lung cancer, preoperative ambulatory status and the number of involved vertebrae were significant prognostic factors associated with their survival.