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Bobinski L, Axelsson J, Melhus J, Åkerstedt J, Wänman J. The Spinal Instability Neoplastic Score correlates with epidural spinal cord compression -a retrospective cohort of 256 surgically treated patients with spinal metastases. BMC Musculoskelet Disord 2024; 25:644. [PMID: 39148117 PMCID: PMC11325593 DOI: 10.1186/s12891-024-07756-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 08/02/2024] [Indexed: 08/17/2024] Open
Abstract
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.
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Affiliation(s)
- Lukas Bobinski
- Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
| | - Joel Axelsson
- Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
| | - Jonathan Melhus
- Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
| | - Josefin Åkerstedt
- Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
| | - Johan Wänman
- Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden.
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Santipas B, Veerakanjana K, Ittichaiwong P, Chavalparit P, Wilartratsami S, Luksanapruksa P. Development and internal validation of machine-learning models for predicting survival in patients who underwent surgery for spinal metastases. Asian Spine J 2024; 18:325-335. [PMID: 38764230 PMCID: PMC11222881 DOI: 10.31616/asj.2023.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 05/21/2024] Open
Abstract
STUDY DESIGN A retrospective study. PURPOSE This study aimed to develop machine-learning algorithms for predicting survival in patients who underwent surgery for spinal metastasis. OVERVIEW OF LITERATURE This study develops machine-learning models to predict postoperative survival in spinal metastasis patients, filling the gaps of traditional prognostic systems. Utilizing data from 389 patients, the study highlights XGBoost and CatBoost algorithms̓ effectiveness for 90, 180, and 365-day survival predictions, with preoperative serum albumin as a key predictor. These models offer a promising approach for enhancing clinical decision-making and personalized patient care. METHODS A registry of patients who underwent surgery (instrumentation, decompression, or fusion) for spinal metastases between 2004 and 2018 was used. The outcome measure was survival at postoperative days 90, 180, and 365. Preoperative variables were used to develop machine-learning algorithms to predict survival chance in each period. The performance of the algorithms was measured using the area under the receiver operating characteristic curve (AUC). RESULTS A total of 389 patients were identified, with 90-, 180-, and 365-day mortality rates of 18%, 41%, and 45% postoperatively, respectively. The XGBoost algorithm showed the best performance for predicting 180-day and 365-day survival (AUCs of 0.744 and 0.693, respectively). The CatBoost algorithm demonstrated the best performance for predicting 90-day survival (AUC of 0.758). Serum albumin had the highest positive correlation with survival after surgery. CONCLUSIONS These machine-learning algorithms showed promising results in predicting survival in patients who underwent spinal palliative surgery for spinal metastasis, which may assist surgeons in choosing appropriate treatment and increasing awareness of mortality-related factors before surgery.
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Affiliation(s)
- Borriwat Santipas
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanyakorn Veerakanjana
- Siriraj Informatics and Data Innovation Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyalitt Ittichaiwong
- Siriraj Informatics and Data Innovation Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piya Chavalparit
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Orthopaedic Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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McCabe FJ, McCabe JP, Murray O. A novel scoring system incorporating sarcopenia to predict postoperative survival in spinal metastasis. Spine J 2023; 23:1270-1275. [PMID: 37116718 DOI: 10.1016/j.spinee.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/02/2023] [Accepted: 04/18/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND CONTEXT As the prevalence of spinal metastasis rises, methods to predict survival will become increasingly important for clinical decision-making. Sarcopenia may be used to predict survival in these patients. PURPOSE The purpose of this study to develop a prediction model incorporating sarcopenia for postoperative survival in patients with spinal metastasis. DESIGN Retrospective cohort study. PATIENT SAMPLE This study included 200 patients who underwent operative intervention for spinal metastasis in our institution, a tertiary, academic spine center. OUTCOME MEASURES The primary outcome measure was 1-year postoperative survival. The secondary outcome measures were 3-month and 6-month postoperative survival. METHODS Clinicopathological and survivorship data was collated. Sarcopenia was defined using the L3 Psoas/Vertebral Body Ratio on cross-sectional CT. Independent predictors of postoperative survival were assessed by multiple logistic regression. RESULTS Overall 1-year postoperative survival was 50%. L3/Psoas ratio ≥1.5 (OR 6.2), albumin ≥35g/l (OR 3.0) and primary tumor type were found to be independent predictors of 3 month, 6 month and 1 year postoperative survival on multivariable analysis. Age at surgery, ambulatory status and mode of presentation were not independent predictors of survival. Variables were used to generate a new scoring system, ProgMets, to predict postoperative survival. The ProgMets system had greater correlation and higher area under the curve (AUC, 0.80) for 1-year survival than other scoring systems. CONCLUSIONS This is the first model to incorporate sarcopenia to predict survival in spinal metastasis patients and has good prediction of survival compared to previous models. This tool may be increasingly useful for informed decision making for patients and surgeons.
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Affiliation(s)
- Fergus J McCabe
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland; University of Galway, Galway, Ireland.
| | - John P McCabe
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland; University of Galway, Galway, Ireland
| | - Odhrán Murray
- Spine Service, Department of Trauma and Orthopedic Surgery, Galway University Hospitals, Galway, Ireland
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Bulthuis VJ, Schuermans VNE, Willems PC, Curfs I, Ramos Gonzaléz AA, van Kuijk SMJ, Santbrink HV. Predicting Survival in Patients Presenting With Spinal Epidural Metastases: The Limburg Spinal Metastasis Score. Int J Spine Surg 2023; 17:547-556. [PMID: 37085320 PMCID: PMC10478688 DOI: 10.14444/8473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Patients with spinal epidural metastases (SEM) often experience a reduction in ambulatory status and, thus, the quality of life. Predicting which patients will benefit from a surgical intervention remains a challenge. Life expectancy is an essential factor to be considered in surgical decision-making, although not the only one. Prediction models can add value in surgical decision-making. The goal of this study was to develop and internally validate a novel model (Limburg spinal metastases score [LSMS]) and compare the predictive value with 2 commonly used models: modified Bauer score and Oswestry Spinal Risk Index (OSRI). METHODS We retrospectively analyzed 144 consecutive patients who underwent surgical decompression for SEM in our centers between November 2006 and December 2020. Clinical and surgical parameters were evaluated. The novel prediction model was based on multivariate analysis and was internally validated. External validation of the 2 most commonly used prediction models was performed. RESULTS The median survival was 17 months, 55.7% of the immobile patients regained ambulation postoperatively. In 50 patients (34.7%), at least 1 complication occurred within 30 days after surgery. The LSMS consists of 4 parameters: primary tumor type, Karnofsky performance score, presence of visceral metastases, and presence of multiple spinal metastases. Bootstrap internal validation of the model developed on this cohort yielded an optimism-corrected c-statistic of 0.75 (95% CI: 0.71-0.80). The c-statistic of the OSRI score and the Bauer score was 0.69 (95% CI: 0.64-0.74) and 0.67 (95% CI: 0.62-0.72), respectively. CONCLUSION The LSMS consists of 4 parameters to assist surgical decision-making for patients with SEM. The score is easy to use and appears more accurate in our population in comparison with previous existing models. CLINICAL RELEVANCE A novel prediction model was developed to aid in surgical decision-making for patients with spinal epidural metastases. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Vincent J Bulthuis
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Heerlen, Netherlands
- Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Valérie N E Schuermans
- Department of Neurosurgery, Zuyderland Medical Center, Heerlen, Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Paul C Willems
- Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Inez Curfs
- Department of Orthopedic Surgery, Zuyderland Medical Center, Heerlen, Netherlands
| | | | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology (KEMTA), Maastricht University Medical Center, Maastricht, Netherlands
| | - Henk van Santbrink
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
- Department of Neurosurgery, Zuyderland Medical Center, Heerlen, Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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5
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Wick JB, Kalistratova VS, Jr DP, Fine JR, Boozé ZL, Holland J, Vander Voort W, Hisatomi LA, Villegas A, Conry K, Ortega B, Javidan Y, Roberto RF, Klineberg EO, Le HV. A Comparison of Prognostic Models to Facilitate Surgical Decision-Making for Patients With Spinal Metastatic Disease. Spine (Phila Pa 1976) 2023; 48:567-576. [PMID: 36799724 DOI: 10.1097/brs.0000000000004600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/30/2022] [Indexed: 02/18/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Compare the performance of and provide cutoff values for commonly used prognostic models for spinal metastases, including Revised Tokuhashi, Tomita, Modified Bauer, New England Spinal Metastases Score (NESMS), and Skeletal Oncology Research Group model, at three- and six-month postoperative time points. SUMMARY OF BACKGROUND DATA Surgery may be recommended for patients with spinal metastases causing fracture, instability, pain, and/or neurological compromise. However, patients with less than three to six months of projected survival are less likely to benefit from surgery. Prognostic models have been developed to help determine prognosis and surgical candidacy. Yet, there is a lack of data directly comparing the performance of these models at clinically relevant time points or providing clinically applicable cutoff values for the models. MATERIALS AND METHODS Sixty-four patients undergoing surgery from 2015 to 2022 for spinal metastatic disease were identified. Revised Tokuhashi, Tomita, Modified Bauer, NESMS, and Skeletal Oncology Research Group were calculated for each patient. Model calibration and discrimination for predicting survival at three months, six months, and final follow-up were evaluated using the Brier score and Uno's C, respectively. Hazard ratios for survival were calculated for the models. The Contral and O'Quigley method was utilized to identify cutoff values for the models discriminating between survival and nonsurvival at three months, six months, and final follow-up. RESULTS Each of the models demonstrated similar performance in predicting survival at three months, six months, and final follow-up. Cutoff scores that best differentiated patients likely to survive beyond three months included the Revised Tokuhashi score=10, Tomita score=four, Modified Bauer score=three, and NESMS=one. CONCLUSION We found comparable efficacy among the models in predicting survival at clinically relevant time points. Cutoff values provided herein may assist surgeons and patients when deciding whether to pursue surgery for spinal metastatic disease. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Joseph B Wick
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | | | | | - Jeffrey R Fine
- University of California, Davis, Department Biostatistics, Sacramento, CA
| | - Zachary L Boozé
- University of California, Davis, School of Medicine, Sacramento, CA
| | - Joseph Holland
- University of Louisville School of Medicine, Louisville, KY
| | - Wyatt Vander Voort
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | | | - Alex Villegas
- University of California, Davis, School of Medicine, Sacramento, CA
| | - Keegan Conry
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Brandon Ortega
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Yashar Javidan
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Rolando F Roberto
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Hai V Le
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
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Dobran M, Lisi SV, Di Rienzo A, Carrassi E, Capece M, Dorato P, di Somma LGM, Iacoangeli M. Evaluation of prognostic preoperative factors in patients undergoing surgery for spinal metastases: Results in a consecutive series of 81 cases. Surg Neurol Int 2022; 13:363. [PMID: 36128147 PMCID: PMC9479529 DOI: 10.25259/sni_276_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Surgical treatment of spinal metastases should be tailored to provide pain control, neurological deficit improvement, and vertebral stability with low operative morbidity and mortality. The aim of this study was to analyze the predictive value of some preoperative factors on overall survival in patients undergoing surgery for spinal metastases. Methods: We retrospectively analyzed a consecutive series of 81 patients who underwent surgery for spinal metastases from 2015 and 2021 in the Clinic of Neurosurgery of Ancona (Italy). Data regarding patients’ baseline characteristics, preoperative Karnofsky Performance Status Score (KPS), and Frankel classification grading system, histology of primary tumor, Tokuhashi revised and Tomita scores, Spine Instability Neoplastic Score, and Epidural Spinal Cord Compression Classification were collected. We also evaluated the interval time between the diagnosis of the primary tumor and the onset of spinal metastasis, the type of surgery, the administration of adjuvant therapy, postoperative pain and Frankel grade, and complications after surgery. The relationship between patients’ overall survival and predictive preoperative factors was analyzed by the Kaplan–Meier method. For the univariate and multivariate analysis, the log-rank test and Cox regression model were used. P ≤ 0.05 was considered as statistically significant. Results: After surgery, the median survival time was 13 months. In our series, the histology of the primary tumor (P < 0.001), the Tomita (P < 0.001) and the Tokuhashi revised scores (P < 0.001), the preoperative KPS (P < 0.001), the adjuvant therapy (P < 0.001), the postoperative Frankel grade (P < 0.001), and the postoperative pain improvement (P < 0.001) were significantly related to overall survival in the univariate analysis. In the multivariate analysis, the Tomita (P < 0.001), Tokuhashi revised scores (P < 0.001), and the adjuvant therapy were confirmed as independent prognostic factors. Conclusion: These data suggest that patients with limited extension of primitive tumor and responsive to the adjuvant therapy are the best candidates for surgery with better outcome.
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7
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Nakajima H, Watanabe S, Honjoh K, Izubuchi Y, Watanabe Y, Tanaka T, Matsumine A. Prognosis after Palliative Surgery for Patients with Spinal Metastasis: Comparison of Predicted and Actual Survival. Cancers (Basel) 2022; 14:cancers14163868. [PMID: 36010862 PMCID: PMC9405944 DOI: 10.3390/cancers14163868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary Increased options for cancer treatment have made the prediction of prognosis an important factor in therapeutic decision making. The aim of this study was to assess the clinical significance of prognosis–scoring systems and to identify predictors for 6–month mortality after palliative surgery. The median actual survival period was longer than the predicted life expectancy based on the revised Tokuhashi score and new Katagiri score. However, 21.3% of patients died of cancers within 6 months after palliative surgery. A statistical analysis showed that a higher CRP/albumin ratio (odds ratio: 0.39; cut–off 0.409) and absence of postoperative adjuvant therapy (odds ratio: 7.15) were independent risk factors for poor survival. Our findings suggest the need for careful consideration to determine if palliative surgery is the best option for a patient with these negative prognostic factors, regardless of life expectancy predicted based on a prognosis score. Abstract Prediction of prognosis is a key factor in therapeutic decision making due to recent the development of therapeutic options for spinal metastases. The aim of the study was to examine predictive scoring systems and identify prognostic factors for 6–month mortality after palliative surgery. The participants were 75 patients with spinal metastases who underwent palliative surgery and had a minimum follow–up period of 1 year. Associations of actual survival with categories based on the revised Tokuhashi score and new Katagiri score were evaluated. Univariate and multivariate analyses were performed to identify prognostic factors for 6–month mortality after palliative surgery. The median actual survival period was longer than those predicted using the scoring systems. However, 21.3% of patients died of cancers within 6 months after surgery. A higher CRP/albumin ratio (odds ratio: 0.39; cut–off 0.409) and absence of postoperative adjuvant therapy (odds ratio: 7.15) were independent risk factors for 6–month mortality. There was no association of mortality with primary site, severity of sarcopenia, or other biomarkers. These results suggest that careful consideration is needed to determine whether palliative surgery is the best option for patients with a high preoperative CRP/albumin ratio and/or absence of postoperative adjuvant therapy, regardless of predictions made from scoring systems.
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Sullivan PZ, Niu T, Abinader JF, Syed S, Sampath P, Telfeian A, Fridley J, Klinge P, Camara J, Oyelese A, Gokaslan ZL. Evolution of surgical treatment of metastatic spine tumors. J Neurooncol 2022; 157:277-283. [PMID: 35306618 DOI: 10.1007/s11060-022-03982-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/04/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The treatment of cancer has transformed over the past 40 years, with medical oncologists, radiation oncologists and surgeons working together to prolong survival times and minimize treatment related morbidity. With each advancement, the risk-benefit scale has been calibrated to provide an accurate assessment of surgical hazard. The goal of this review is to look back at how the role of surgery has evolved with each new medical advance, and to explore the role of surgeons in the future of cancer care. METHODS A literature review was conducted, highlighting the key papers guiding surgical management of spinal metastatic lesions. CONCLUSION The roles of surgery, medical therapy, and radiation have evolved over the past 40 years, with new advances requiring complex multidisciplinary care.
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Affiliation(s)
- Patricia Zadnik Sullivan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA.
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Jose Fernandez Abinader
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Sohail Syed
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Prakash Sampath
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Albert Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Jared Fridley
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Petra Klinge
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Joaquin Camara
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Adetokunbo Oyelese
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 593 Eddy St, APC 6, Providence, RI, 02903, USA
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Schoenfeld AJ, Ferrone ML, Blucher JA, Agaronnik N, Nguyen L, Tobert DG, Balboni TA, Schwab JH, Shin JH, Sciubba DM, Harris MB. Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases. Spine J 2022; 22:39-48. [PMID: 33741509 PMCID: PMC8443703 DOI: 10.1016/j.spinee.2021.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/16/2021] [Accepted: 03/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data. PURPOSE To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment. PATIENT SAMPLE We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019. OUTCOME MEASURES One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily. METHODS All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score. RESULTS When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score. CONCLUSIONS The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Nicole Agaronnik
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Lananh Nguyen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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10
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Tabourel G, Terrier LM, Dubory A, Cristini J, Nail LRL, Cook AR, Buffenoir K, Pascal-Moussellard H, Carpentier A, Mathon B, Amelot A. Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance. J Neurosurg Spine 2021; 35:527-534. [PMID: 34298515 DOI: 10.3171/2020.12.spine201741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM. METHODS It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017. RESULTS In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita's prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35-0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64-0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54-0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen's kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen's kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a "slight" rate of agreement (weighted Cohen's kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival. CONCLUSIONS The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.
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Affiliation(s)
- Gaston Tabourel
- 1Department of Neurosurgery, Bretonneau Hospital, Tours
- 2Department of Neurosurgey/Neurotraumatology, Hôtel-Dieu Hospital, Nantes
| | | | - Arnaud Dubory
- 3Department of Orthopedic Surgery, Mondor Hospital-APHP, Créteil
| | - Joseph Cristini
- 2Department of Neurosurgey/Neurotraumatology, Hôtel-Dieu Hospital, Nantes
| | | | - Ann-Rose Cook
- 1Department of Neurosurgery, Bretonneau Hospital, Tours
| | - Kévin Buffenoir
- 2Department of Neurosurgey/Neurotraumatology, Hôtel-Dieu Hospital, Nantes
| | | | | | - Bertrand Mathon
- 6Neurosurgery, La Pitié-Salpêtrière Hospital-APHP, Paris, France
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11
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Smeijers S, Depreitere B. Prognostic scores for survival as decisional support for surgery in spinal metastases: a performance assessment systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2800-2824. [PMID: 34398337 DOI: 10.1007/s00586-021-06954-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 07/02/2021] [Accepted: 08/01/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To review the evidence on the relative prognostic performance of the available prognostic scores for survival in spinal metastatic surgery in order to provide a recommendation for use in clinical practice. METHODS A systematic review of comparative external validation studies assessing the performance of prognostic scores for survival in independent cohorts was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Eligible studies were identified through Medline and Embase until May 2021. Studies were included when they compared at least four survival scoring systems in surgical or mixed cohorts across all primary tumor types. Predictive performance was assessed based on discrimination and calibration for 3-month, 1-year and overall survival, and generalizability was assessed based on the characteristics of the development cohort and external validation cohorts. Risk of bias and concern regarding applicability were assessed based on the 'Prediction model study Risk Of Bias Assessment Tool' (PROBAST). RESULTS Twelve studies fulfilled the inclusion criteria and covered 17 scoring systems across 5.130 patients. Several scores suffer from suboptimal development and validation. The SORG Nomogram, developed in a large surgical cohort, showed good discrimination on 3-month and 1-year survival, good calibration and was superior in direct comparison with low risk of bias and low concern regarding applicability. Machine learning algorithms are promising as they perform equally well in direct comparison. Tokuhashi, Tomita and other traditional risk scores showed suboptimal performance. CONCLUSION The SORG Nomogram and machine learning algorithms outline superior performance in survival prediction for surgery in spinal metastases. Further improvement by comparative validation in large multicenter, prospective cohorts can still be obtained. Given the heterogeneity of spinal metastases, superior methodology of development and validation is key in improving future machine learning systems.
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Affiliation(s)
- S Smeijers
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - B Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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12
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A Novel Clinical Scoring System for Perioperative Morbidity in Metastatic Spinal Tumor Surgery: The Spine Oncology Morbidity Assessment Score. Spine (Phila Pa 1976) 2021; 46:E161-E166. [PMID: 33038202 DOI: 10.1097/brs.0000000000003733] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Prospective validation of a clinical prediction score for survival in patients with spinal metastases: the New England Spinal Metastasis Score. Spine J 2021; 21:28-36. [PMID: 32087387 DOI: 10.1016/j.spinee.2020.02.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/04/2020] [Accepted: 02/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS. PURPOSE To prospectively validate the NESMS. STUDY DESIGN Prospective longitudinal observational cohort study. PATIENT SAMPLE Patients, aged 18 and older, presenting for treatment with spinal metastatic disease. OUTCOME MEASURES One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary). METHODS The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI). RESULTS This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall. CONCLUSIONS This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy.
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Pennington Z, Ehresman J, Cottrill E, Lubelski D, Lehner K, Feghali J, Ahmed AK, Schilling A, Sciubba DM. To operate, or not to operate? Narrative review of the role of survival predictors in patient selection for operative management of patients with metastatic spine disease. J Neurosurg Spine 2021; 34:135-149. [PMID: 32916652 DOI: 10.3171/2020.6.spine20707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
Accurate prediction of patient survival is an essential component of the preoperative evaluation of patients with spinal metastases. Over the past quarter of a century, a number of predictors have been developed, although none have been accurate enough to be instituted as a staple of clinical practice. However, recently more comprehensive survival calculators have been published that make use of larger data sets and machine learning to predict postoperative survival among patients with spine metastases. Given the glut of calculators that have been published, the authors sought to perform a narrative review of the current literature, highlighting existing calculators along with the strengths and weaknesses of each. In doing so, they identify two "generations" of scoring systems-a first generation based on a priori factor weighting and a second generation comprising predictive tools that are developed using advanced statistical modeling and are focused on clinical deployment. In spite of recent advances, the authors found that most predictors have only a moderate ability to explain variation in patient survival. Second-generation models have a greater prognostic accuracy relative to first-generation scoring systems, but most still require external validation. Given this, it seems that there are two outstanding goals for these survival predictors, foremost being external validation of current calculators in multicenter prospective cohorts, as the majority have been developed from, and internally validated within, the same single-institution data sets. Lastly, current predictors should be modified to incorporate advances in targeted systemic therapy and radiotherapy, which have been heretofore largely ignored.
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CANDIDO PRISCILABARILEMARCHI, PERRIA FERNANDAMARIA, COSTA HERTONRODRIGODA, DEFINO HELTONLUIZAPARECIDO. A COMPARISON OF THE TOMITA AND TOKUHASHI SCORES IN SPINAL METASTASIS. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201904238102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective To compare Tokuhashi and Tomita scores in patients with epidural spinal metastasis who underwent surgical treatment. Methods A retrospective evaluation of 103 patients with spinal metastasis and epidural compression who underwent surgical treatment. An analysis was performed of agreement between the survival rates observed in the study sample and the survival rate estimated by the Tomita and Tokuhashi scales. Results The overall accuracy was 39.03% for the Tomita scale and 61.75% for the Tokuhashi scale. Fair agreement (0.38 weighted Cohen’s Kappa coefficient) was observed between patient survival and the Tokuhashi score, and slight agreement (0.25 weighted Kappa coefficient) for the Tomita score. The agreement for both scales was higher for patients with less than six months’ survival, with general accuracy of 79.17% for the Tomita and 70.59% for the Tokuhashi scoring system. Conclusion There was fair and slight agreement between the Tokuhashi and Tomita scores with patient survival group. The agreement was higher for patients with less than six months’ survival. Level of evidence III; Comparative retrospective study.
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Alpantaki K, Ioannidis A, Raptis K, Spartalis E, Koutserimpas C. Surgery for spinal metastatic tumors: Prognostication systems in clinical practice (Review). Mol Clin Oncol 2020; 12:399-402. [PMID: 32257194 DOI: 10.3892/mco.2020.2008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/03/2020] [Indexed: 12/12/2022] Open
Abstract
The management of spinal metastatic tumors is a matter of increasing clinical importance, as 20-40% of cancer patients have evidence of vertebral metastatic disease at the time of their passing and up to 20% develop neurological symptoms due to epidural spinal cord compression. The treatment of patients with spinal metastases is challenging, albeit palliative, and it requires a multidisciplinary approach. Accurate prediction of life expectancy of patients with cancer is of paramount importance for therapeutic strategy. Prognostication scoring systems were developed to aid clinicians to follow a more objective, safe and evidence-based approach with therapy selection and surgical intervention indications. In this context, the aim of the present review was to briefly discuss the evolution of scoring systems since their introduction in the early 90s until today, their advantages and shortcomings, and the future requirements for personalized scoring in the era of modern oncology.
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Affiliation(s)
- Kalliopi Alpantaki
- Department of Orthopaedics, 'Venizeleion' General Hospital, Heraklion, Crete 71409, Greece
| | - Argyrios Ioannidis
- Department of General, Laparoscopic, Oncologic and Robotic Surgery, Athens Medical Center, Athens 15125, Greece
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, '251' Hellenic Air Force General Hospital, Athens 11525, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Christos Koutserimpas
- Department of Orthopaedics and Traumatology, '251' Hellenic Air Force General Hospital, Athens 11525, Greece
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Sim DS, Zainul-Abidin S, Sim EY, Seng CS, Tan SEE, Tan MH, Howe TS, Koh JSB. Serum albumin level predicts survival after surgical treatment of metastatic femur fractures: a retrospective study. J Orthop Surg Res 2020; 15:128. [PMID: 32245389 PMCID: PMC7118955 DOI: 10.1186/s13018-020-01632-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/12/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Surgical treatment for metastatic pathological femur fractures is associated with high mortality. Correct estimation of prognosis helps in determining the palliative value of surgical treatment and informs surgical decision. This study evaluates the risk factors for mortality in these patients who were surgically treated. METHODS This is a retrospective study of 112 patients with surgical treatment of metastatic pathological femur fractures. Risk factors evaluated included age, ASA status, Charlson comorbidity index, preoperative serum albumin and haemoglobin, primary tumour site, presence of visceral metastases, presence of spinal metastases, time from diagnosis of cancer to occurrence of pathological fracture, type of surgical procedure performed, lesion and whether treatment was received for an actual or impending fracture. A Cox regression model was used to determine if these factors were independent significant factors for survival. RESULTS Mortality at 2 years after surgical treatment of metastatic femoral fractures was 86%. Cox regression analysis of risk factors revealed that preoperative serum albumin and type primary tumour were independent risk factors for mortality. Presence of visceral metastases was strongly correlated to serum albumin levels. CONCLUSION Preoperative serum albumin level and primary tumour site are independent risk factors of survival in patients treated for pathological femur fractures. Serum albumin level may be used as a prognostic tool to guide treatment in this cohort of patients with high mortality rates.
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Affiliation(s)
- David Shaoen Sim
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore. .,, Singapore, Singapore.
| | | | - Eileen Yilin Sim
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Chu Sheng Seng
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | | | - Mann Hong Tan
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Tet Sen Howe
- Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
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Design of the prospective observational study of spinal metastasis treatment (POST). Spine J 2020; 20:572-579. [PMID: 31712164 DOI: 10.1016/j.spinee.2019.10.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There are several prognostic scores available that intend to inform decision-making for patients with spinal metastases. Many of these have not been found to reliably predict survival across the continuum of care. Recently, our group developed the New England Spinal Metastasis Score (NESMS). While the NESMS demonstrated many of the necessary attributes of a useful prediction tool, it has yet to be validated prospectively. PURPOSE To describe the prospective observational study of spinal metastasis treatment (POST). This investigation examined the performance of the NESMS, compared its predictive capacity with other scoring systems and determined its ability to identify patients who benefit the most from surgery. STUDY DESIGN Prospective observational study at two medical centers. PATIENT SAMPLE Patients age 18 and older with spinal metastases involving the spine. OUTCOME MEASURES Survival, post-treatment morbidity and health-related quality of life outcomes. METHODS The POST study assessed patients at baseline and at 1-month, 3-month, 6-month, and 12-month time-points. During the baseline assessment patient demographics, past medical history and assessment of co-morbidities, surgical history, primary tumor histology, and ambulatory status were recorded along with the designated treatment strategy (eg, operative or nonoperative). The NESMS and other predictive scores for each patient were calculated based on baseline data. Study-specific surveys administered at all time-points consisted of the EuroQuol 5-Dimension and Short-Form (SF)-12, Visual Analog Scale (VAS) for pain, and PROMIS assessment of global health. RESULTS Two hundred patients were enrolled in POST from 2017 to 2019. Patients were followed to one of the two predetermined study end-points (ie, mortality, or completion of the 12-month follow-up). Survival was considered the principle dependent variable. Post-treatment morbidity and health-related quality of life outcomes were considered secondarily. Analyses, by aim, relied on Cox proportional hazards regression, repeated measures logistic regression, propensity score matching and multivariable logistic regression. CONCLUSION The POST's findings are anticipated to provide evidence regarding the prognostic capabilities of the NESMS as well as that of other popular grading schemes for survival, post-treatment complications and physical as well as mental function.
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Cook WH, Baker JF. Retrospective evaluation of prognostic factors in metastatic spine disease: serum albumin and primary tumour type are key. ANZ J Surg 2020; 90:1070-1074. [DOI: 10.1111/ans.15821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 12/26/2022]
Affiliation(s)
- William H. Cook
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
| | - Joseph F. Baker
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- Department of Orthopaedic SurgeryWaikato Hospital Hamilton New Zealand
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Costa M, Campello LB, Ryan M, Rochester J, Viceconti M, Dall'Ara E. Effect of size and location of simulated lytic lesions on the structural properties of human vertebral bodies, a micro-finite element study. Bone Rep 2020; 12:100257. [PMID: 32551335 PMCID: PMC7292861 DOI: 10.1016/j.bonr.2020.100257] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/07/2020] [Accepted: 03/06/2020] [Indexed: 11/25/2022] Open
Abstract
Currently, the Spinal Instability Neoplastic Score system is used in clinics to evaluate the risk of fracture in patients with spinal metastases. This method, however, does not always provide a clear guideline due to the complexity in accounting for the effect of metastatic lesions on vertebral stability. The aim of this study was to use a validated micro Finite Element (microFE) modelling approach to analyse the effect of the size and location of lytic metastases on the mechanical properties of human vertebral bodies. Micro Computed Tomography based microFE models were generated with and without lytic lesions simulated as holes within a human vertebral body. Single and multiple lytic lesions were simulated with four different sizes and in five different locations. Bone was assumed homogenous, isotropic and linear elastic, and each vertebra was loaded in axial compression. It was observed that the size of lytic lesions was linearly related with the reduction in structural properties of the vertebral body (reduction of stiffness between 3% and 30% for lesion volume between 4% and 35%). The location of lytic lesions did not show a clear effect on predicted structural properties. Single or multiple lesions with the same volume provided similar results. Locally, there was a homogeneous distribution of axial principal strains among the models with and without lytic lesions. This study highlights the potential of microFE models to study the effect of lesions on the mechanical properties of the human vertebral body. MicroFE models can show the effect of lytic lesions on vertebral properties. The size of the lesions was more critical than the location of the lesions. Lesions affecting the cortical shell had a larger effect on the local strains. Multiple lesions showed a similar effect to single lesions.
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Affiliation(s)
- M.C. Costa
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
| | | | - M. Ryan
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
| | - J. Rochester
- Academic Unit of Medical Education, Medical School, University of Sheffield, UK
| | - M. Viceconti
- Department of Industrial Engineering, Alma Mater Studiorum - University of Bologna, Italy
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - E. Dall'Ara
- Department of Oncology and Metabolism, Mellanby Centre for bone Research, University of Sheffield, UK
- INSIGNEO Institute for in silico Medicine, University of Sheffield, UK
- Corresponding author at: The Pam Liversidge Building, Sir Robert Hadfield Building, Mappin Street, Sheffield S1 3JD, UK.
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Dakson A, Leck E, Brandman DM, Christie SD. The clinical utility of the Spinal Instability Neoplastic Score (SINS) system in spinal epidural metastases: a retrospective study. Spinal Cord 2020; 58:892-899. [PMID: 32047252 DOI: 10.1038/s41393-020-0432-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVES This study assessed the clinical utility of the Spinal Instability Neoplastic Score (SINS) in relation to the surgical treatment of spinal epidural metastasis and factors important for surgical decision-making. These factors include epidural spinal cord compression (ESCC), patient prognosis and neurologic status. SETTING Queen Elizabeth II Health Sciences Centre, Halifax, Canada. METHODS We identified 285 patients with spinal metastatic disease. Data were extracted through a retrospective review. SINS and ESCC were scored based on CT and MRI, respectively. RESULTS Patients were grouped into stable (35%), potentially unstable (52%), and unstable (13%) groups. The overall incidence of metastatic spinal deformity was 9%. Surgical interventions were performed in 21% of patients, including decompression and instrumented fusion (70%), decompression alone (17%), percutaneous vertebral augmentation (9%), and instrumented vertebral augmentation (5%). The use of spinal instrumentation was significantly associated with unstable SINS (p = 0.005). Grade 3 ESCC was also significantly associated with unstable SINS (p < 0.001). Kaplan-Meier analysis revealed that SINS was not a predictor of survival (p = 0.98). In the radiotherapy-alone group, a significant proportion of patients with potentially unstable SINS (30%) progressed into unstable SINS category at an average 364 ± 244 days (p < 0.001). CONCLUSION This study demonstrated that more severe categories of SINS were associated with higher degrees of ESCC, and surgical interventions were more often utilized in this group with more frequent placement of spinal instrumentation. Although SINS did not predict patient prognosis, it correlates with the progression of metastatic instability in patients treated with radiotherapy.
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Affiliation(s)
- Ayoub Dakson
- Division of Neurosurgery, Halifax Infirmary, 1796 Summer Street, Room 3814, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Erika Leck
- Division of Neurosurgery, Halifax Infirmary, 1796 Summer Street, Room 3814, Halifax, Nova Scotia, B3H 3A7, Canada
| | - David M Brandman
- Division of Neurosurgery, Halifax Infirmary, 1796 Summer Street, Room 3814, Halifax, Nova Scotia, B3H 3A7, Canada
| | - Sean D Christie
- Division of Neurosurgery, Halifax Infirmary, 1796 Summer Street, Room 3814, Halifax, Nova Scotia, B3H 3A7, Canada.
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Mezei T, Horváth A, Pollner P, Czigléczki G, Banczerowski P. Research on the predicting power of the revised Tokuhashi system: how much time can surgery give to patients with short life expectancy? Int J Clin Oncol 2020; 25:755-764. [PMID: 31993865 PMCID: PMC7118051 DOI: 10.1007/s10147-019-01612-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/10/2019] [Indexed: 12/01/2022]
Abstract
Object The primary treatment option for symptomatic metastatic spinal tumors is surgery. Prognostic systems are designed to assist in the establishment of the indication and the choice of surgical methodology. The best-known prognostic system is the revised Tokuhashi system, which has a predictive ability of about 60%. In our study, we are attempting to find the reason for its poor predictive ability, despite its proper separation ability. Methods We have designed a one-center-based retrospective clinical trial, by which we would like to test the feasibility and the inaccuracy of the revised Tokuhashi system. In our database, there are 329 patients who underwent surgery. Statistical analysis was performed. Results A significant increase in survival time was observed in the ‘conservative’ category. Earlier studies reported OS 0.15 at the 180-day control time, in contrast with our 0.38 OS value. The literature suggested supportive care for this category, but in our population, every patient underwent surgery. Our population passes the 0.15 OS value on day 475. We propose an adjustment of the Tokuhashi category scores. We observed significant success in resolving pain. Motor functions were improved or stabilized compared to changes in vegetative dysfunction. Conclusion According to our results, the Tokuhashi scoring system makes very conservative predictions and prefers non-surgical palliative or supportive care. Surgical treatment increases the life expectancy of patients in poor condition. We propose modifying the therapeutic options of the revised Tokuhashi system, taking into consideration modern spine surgery techniques.
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Affiliation(s)
- Tamás Mezei
- Department of Neurosurgery, Semmelweis University, 57 Amerikai Rd, Budapest, 1145, Hungary. .,National Institute of Clinical Neurosciences, 57 Amerikai Rd, Budapest, 1145, Hungary.
| | - Anna Horváth
- 3rd Department of Internal Medicine, Semmelweis University, 4 Kútvölgyi Rd, Budapest, 1125, Hungary
| | - Péter Pollner
- MTA-ELTE Statistical and Biological Physics Research Group, 1/a. Pázmány Péter S., Budapest, 1117, Hungary.,Health Services Management Training Center, Semmelweis University, 2 Kútvölgyi Rd, Budapest, 1125, Hungary
| | - Gábor Czigléczki
- Department of Neurosurgery, Semmelweis University, 57 Amerikai Rd, Budapest, 1145, Hungary.,National Institute of Clinical Neurosciences, 57 Amerikai Rd, Budapest, 1145, Hungary
| | - Péter Banczerowski
- Department of Neurosurgery, Semmelweis University, 57 Amerikai Rd, Budapest, 1145, Hungary.,National Institute of Clinical Neurosciences, 57 Amerikai Rd, Budapest, 1145, Hungary
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Schoenfeld AJ, Schwab JH, Ferrone ML, Blucher JA, Balboni TA, Barton LB, Chi JH, Kang JD, Losina E, Katz JN. Non-operative management of spinal metastases: A prognostic model for failure. Clin Neurol Neurosurg 2020; 188:105574. [PMID: 31707291 PMCID: PMC6949394 DOI: 10.1016/j.clineuro.2019.105574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/11/2019] [Accepted: 10/26/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe patient-specific characteristics associated with non-operative failure leading to surgery. PATIENTS AND METHODS We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. RESULTS We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). CONCLUSION We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02214, United States
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Lauren B Barton
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - John H Chi
- Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - James D Kang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Elena Losina
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
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Westermann L, Olivier AC, Samel C, Eysel P, Herren C, Sircar K, Zarghooni K. Analysis of seven prognostic scores in patients with surgically treated epidural metastatic spine disease. Acta Neurochir (Wien) 2020; 162:109-119. [PMID: 31781995 DOI: 10.1007/s00701-019-04115-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/21/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic scores have been proposed to guide the treatment of patients with metastatic spine disease (MSD), but their accuracy and usefulness are controversial. The aim of this study was to evaluate seven such prognostic scoring systems. The following prognostic scores were compared: Tomita, Van der Linden (VDL), Bauer modified (BM), Oswestry Spinal Risk Index (OSRI), Tokuhashi original (T90), Tokuhashi revised (TR05), and modified Tokuhashi revised (TR17). METHODS We retrospectively reviewed all our patients who underwent surgery for spinal metastases, February 2008-January 2015. We classified all 223 patients into the predicted survival-time categories of each of the 7 scoring systems and then tallied how often this was correct vis-à-vis the actual survival time. Accuracy was also assessed using receiver operating characteristic (ROC) analysis at 1, 3, and 12 months. RESULTS The median (95% CI) survival of the 223 patients was 13.6 (7.9-19.3) months. A groupwise ROC analysis showed sufficient accuracy for 3-month survival only for TR17 (area under the curve [AUC] 0.71) and for 1-year survival for T90 (AUC 0.73), TR05 (AUC 0.76), TR17 (AUC 0.76), Tomita (AUC 0.77), and OSRI (AUC 0.71). A pointwise ROC score analysis showed poor prognostic ability for short-term survival (1 and 3 months) with sufficient accuracy for T90 (AUC 0.71), TR05 (AUC 0.71), TR17 (AUC 0.71), and the Tomita score (AUC 0.77) for 1-year survival. CONCLUSION The TR17 was the only prognostic system with acceptable performance here. More sophisticated assessment tools are required to keep up with present and future changes in tumor diagnostics and treatment.
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Affiliation(s)
- Leonard Westermann
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Alain Christoph Olivier
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Christina Samel
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christian Herren
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Krishnan Sircar
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopedics and Traumatology, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Mohd Rothi I, Deverall HH, Baker JF. The modified Frailty Index does not correlate with survival in surgically-treated patients with metastatic spine disease. J Clin Neurosci 2019; 66:178-181. [PMID: 31101585 DOI: 10.1016/j.jocn.2019.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 02/20/2019] [Accepted: 04/28/2019] [Indexed: 01/30/2023]
Abstract
With the increasing burden of metastatic spinal disease there is ever-more pressure on the health system to provide optimal management. Multiple treatment modalities, including surgical intervention, are available. Multiple prognostic scoring systems have been developed to aid both clinician and patient in making the best decision for each individual. The modified Frailty Index (mFI) has not been assessed for its correlation with survival in patients treated for metastatic spine disease. A retrospective review of a patients undergoing surgery for metastatic spine disease at a tertiary referral centre was performed and a comparison was made between the mFI and previously established disease-specific prognostic scores (revised Tokuhashi, modified Bauer and Tomita scores and the Oswestry Spine Risk Index). 41 patients were included over a 5-year period. 38 deceased by the end of the study period with a 30-day mortality of 14.6% and a 1-year mortality of 73.2%. The mFI poorly correlated with survival. Out of the four established scoring system, the OSRI had the best correlation. The mFI did not correlate with survival in this cohort of surgically treated patients with metastatic spinal disease and is best used as a selection tool for surgery. Dedicated prognostic tools can be selected appropriate to the institution experience and set-up.
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Affiliation(s)
| | | | - Joseph F Baker
- Waikato Hospital, New Zealand; University of Auckland, New Zealand
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Treatments and outcomes of spinal metastasis from thymic epithelial tumors: 10-year experience with 15 patients in a single center. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:1520-1528. [DOI: 10.1007/s00586-019-05982-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/19/2019] [Indexed: 12/26/2022]
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