Symptomatic spinal metastasis: A systematic literature review of the preoperative prognostic factors for survival, neurological, functional and quality of life in surgically treated patients and methodological recommendations for prognostic studies

Defining Spine Cancer Pain Syndromes: A Systematic Review and Proposed Terminology

STUDY DESIGN

Systematic Review.

OBJECTIVES

Formalized terminology for pain experienced by spine cancer patients is lacking. The common descriptors of spine cancer pain as mechanical or non-mechanical is not exhaustive. Misdiagnosed spinal pain may lead to ineffective treatment recommendations for cancer patients.

METHODS

We conducted a systematic review of pain terminology that may be relevant to spinal oncology patients. We provide a comprehensive and unbiased summary of the existing evidence, not limited to the spine surgery literature, and subsequently consolidate these data into a practical, clinically relevant nomenclature for spine oncologists.

RESULTS

Our literature search identified 3515 unique citations. Through title and abstract screening, 3407 citations were excluded, resulting in 54 full-text citations for review. Pain in cancer patients is typically described as nociceptive pain (somatic vs visceral), neurologic pain and treatment related pain.

CONCLUSIONS

We consolidate the terminology used in the literature and consolidated into clinically relevant nomenclature of biologic tumor pain, mechanical pain, radicular pain, neuropathic pain, and treatment related pain. This review helps standardize terminology for cancer-related pain which may help clinicians identify pain generators.

Determinants of Overall and Readmission-Free Survival in Patients with Metastatic Epidural Spinal Cord Compression

BACKGROUND

The aim of this study was to assess the surgical outcomes and survival of patients surgically treated for metastatic epidural spinal cord compression (MESCC), with a specific focus on identifying factors that influence overall survival and readmission-free survival.

METHODS

All patients who underwent surgery for spine metastases at our department in the period 2018-2022 were included in the study.

RESULTS

A total of 175 patients (n = 71 females, median age 67.15 years) were included. The most common primary tumors were lung carcinoma (n = 31), prostate carcinoma (n = 31), breast carcinoma (n = 28), multiple myeloma (n = 25), and renal cell carcinoma (n = 11). ECOG performance status was 0 (n = 7), 1 (n = 97), 2 (n = 27), 3 (n = 17), and 4 (n = 27). Pathological fractures were present in n = 108 patients. Decompression only was performed in n = 42, additional instrumentation in n = 133, and vertebral body replacement in n = 23. The most common complications were wound healing deficits and hardware failure. Preoperative motor deficits were present in n = 89 patients. Postoperatively, n = 122 improved, n = 43 was unchanged, and n = 10 deteriorated. Mean overall survival (OS) was 239.2 days, with a 30-day mortality rate of 18.3%. Favorable prognostic factors included Tomita score < 7, Frankel score A-C, ECOG 0-1, and Modified Tokuhashi score > 10 (p < 0.01). Factors affecting OS and readmission-free survival (RFS) included prognostic scores, adjuvant therapy, ASA classification, surgical complications, metastasis number, and postoperative improvement. Better prognostic scores, adjuvant therapy, and clinical improvement were associated with longer OS and RFS, while complications or deterioration resulted in worse outcomes.

CONCLUSIONS

Patients undergoing decompression and/or stabilization for metastatic spinal tumors showed improved outcomes, with favorable prognosis linked to Tomita score < 7, Frankel score A-C, ECOG 0-1, and Modified Tokuhashi score > 10.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Malignant melanoma presenting as isolated thoracic spinal metastases- Case report

INTRODUCTION

Malignant melanoma is a highly invasive tumor with very poor prognosis. Common metastases of MM are noted in lungs, Central nervous system, liver, lymph nodes and isolated spinal metastases are extremely rare. To our knowledge only one case of isolated lumbar spinal metastases of MM was reported.

CASE PRESENTATION

An 80-year-old female presented with pain at upper thoracic spine and progressive weakness of bilateral lower limbs. She gives history of recurrent MM of nose, for which she underwent excision of tumor twice. On examination she had spastic gait with exaggerated lower limb reflexes and lower limb motor grade of 3/5. The MRI scan of thoracic spine revealed lobulated enhancing mass involving the right half of the T3 vertebral body and corresponding posterior elements. The patient underwent palliative spinal decompression and excision of tumor. Histopathology confirmed MM. The PET scan done post operatively ruled out any other sites of metastases.

DISCUSSION

Though the incidence of isolated manifestation of spinal metastases of MM is extremely rare, clinical suspicion and advanced imaging can help to diagnose early. The treatment strategy should be guided by current neurological status, nature of the tumor, presence of mechanical instability and patient's fitness to undergo surgical intervention.

CONCLUSION

Patient diagnosed with MM should be closely followed up even in absence of any recurrence at the primary site. Surgical decompression can improve neurological symptoms and decrease pain to improve quality of life even at advanced stage of the disease.

Hematologic Malignancies Influence the Accuracy of Prediction of Survival in Patients With Solid Tumor Spinal Metastases Undergoing Surgery

PURPOSE

There is no consensus on how to identify patients with multiple-level spinal metastases who would benefit from surgery. Previous studies have revealed that patients with hematologic malignancies have a significantly longer median survival time than those with solid tumor spinal metastases. We aimed to compare predictors and survival data between patients with spinal metastases, including hematologic malignancies (all-malignancies group), with only those with nonhematologic malignancies (nonhematologic malignancies group).

MATERIALS AND METHODS

This single-center retrospective study included all patients age >18 years who underwent surgery to treat spinal metastases in our department from 2008 to 2018. The patients' baseline characteristics, treatment modalities, and laboratory results were analyzed. Survival was calculated from the date of surgery to the date of confirmed death. Cox regression analysis was used to identify independent predictors of survival.

RESULTS

The study cohort comprised 186 patients with a mean age of 57.1 ± 13.4 years, 101 of whom were male and 18 of whom had hematologic malignancies. The median survival time was 201 days in the all-malignancies group and 168 days in the nonhematologic malignancies group. Independent predictors of survival differed between the two groups. Eastern Cooperative Oncology Group status and response to preoperative chemotherapy were identified as independent factors in both groups. However, radiosensitivity and CNS metastases were identified only in the all-malignancies group, and tumor growth potential, albumin status, and number of vertebrae were identified only in the nonhematologic malignancies group. The receiver operating characteristics were comparable in the two groups: 0.75 in the all-malignancies group and 0.77 in the nonhematologic malignancies group.

CONCLUSION

Longer survival in patients with hematologic malignancies influences the overall prediction of survival. Tumor-specific prognostic factors may improve the prediction of survival in patients with spinal metastases.

Evaluation of Conditions for the Development of Cryogenic Spinal Cord Injury Using a Canine Model: An Experimental Study on the Safety of Cryoablation for Metastatic Spinal Tumors

BACKGROUND AND PURPOSE

Although the application of cryoablation to metastatic spinal tumors has been attempted, spinal cryoablation has the unique complication of cryogenic spinal cord injury. This study aimed to elucidate the conditions for the development of cryogenic spinal cord injury.

MATERIALS AND METHODS

Fifteen canines were used in this study. A metal probe was inserted into the 13th thoracic vertebral body. Cryoablation was performed for 10 minutes by freezing the probe in liquid nitrogen. The control canine underwent probe insertion only. Spinal cord monitoring, epidural temperature measurement, motor function assessment, and pathologic examination of the spinal cord were performed.

RESULTS

During the 10 minutes of cryoablation, the epidural temperature decreased and reached the lowest epidural temperature (LET) at the end of cryoablation. The LETs (degrees celsius [°C]) of each canine were -37, -30, -27, -8, -3, -2, 0, 1, 4, 8, 16, 18, 20, and 25, respectively. As the epidural temperature decreased, waveform amplitudes also decreased. At the end of cryoablation (10 minutes after the start of cryoablation), abnormal waves were observed in 92.9% (13/14) of canines. With epidural rewarming, the amplitude of the waveforms tended to recover. After epidural rewarming (2 hours after the start of cryoablation), abnormal waves were observed in 28.6% (4/14) of canines. The LETs (°C) of the canines with abnormal waves after epidural rewarming were -37, -30, -27, and -8. None of the canines with normal waves after epidural rewarming had any motor impairment. In contrast, all canines with remaining abnormal waves after epidural rewarming had motor impairment. In the pathologic assessment, cryogenic changes were found in canines with LETs (°C) of -37 -30, -27, -8, 0, and 1.

CONCLUSIONS

This study showed that 10-minute spinal cryoablation with LETs (°C) of -37, -30, -27, -8, 0, and 1 caused cryogenic spinal cord injury. There was no evidence of cryogenic spinal cord injury in canines with LET of ≥4°C. The epidural temperature threshold for cryogenic spinal cord injury is between 1 and 4°C, suggesting that the epidural temperature should be maintained above at least 4°C to prevent cryogenic spinal cord injury.

Predictors for quality of life, pain and functional outcomes after surgical treatment of metastatic disease in the spine

BACKGROUND

While predictors for postoperative survival in spine tumour patients have been identified, there is limited evidence for predictors of postoperative Quality of Life (QoL), pain and functional outcome.

METHODS

One hundred and fifty-three consecutive patients, who had undergone surgery for symptomatic spinal metastases between June 2016 and April 2019, were interviewed preoperatively and during follow-ups at three, six and 12 months using the EQ-5D-3L, COMI, and ODI questionnaires. Differences in means exceeding the specific Minimal Clinically Important Difference (MCID) values were considered clinically significant.

RESULTS

Thirty-three percent of the patients were reported dead after 12 months. Only one metastasis compared to multiple metastases has 7.9 the Odds for an improved EQ-5D-3L score at three months. No neoadjuvant metastatic irradiation has 6.8 the Odds for the improvement at that time against performed radiation. A preoperative ODI score between 50.1 and 100 has 22.0 times the odds compared to the range from 0 to 50 for an improved EQ-5D-3L after three months, and 12.5 times the odds in favour of improved COMI after three months, and 13.6 times the odds for improvement of ODI at the three-month follow-up. A preoperative COMI score ranging from 5.0 to 10 has 21 times the odds of a COMI between 0 and 5 for an improved EQ-5D-3L score and 11 times the odds for an improved ODI after 12 months. Other predictors showed no statistically significant improvement.

CONCLUSION

An improvement in QoL, pain and spinal function after 12 months can be predicted by a subjective preoperative poor health condition. Impaired spinal function before surgery, a singular metastasis and no previous irradiation is predictive of improved spinal function and quality of life three months after surgery.

Predicting Survival in Patients Presenting With Spinal Epidural Metastases: The Limburg Spinal Metastasis Score

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

Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study

PURPOSE

Allogeneic blood transfusion (ABT) is current standard of blood replenishment despite known complications. Salvaged blood transfusion (SBT) addresses majority of such complications. Surgeons remain reluctant to employ SBT in metastatic spine tumour surgery (MSTS), despite ample laboratory evidence. This prompted us to conduct a prospective clinical study to ascertain safety of intraoperative cell salvage (IOCS), in MSTS.

METHODS

Our prospective study included 73 patients who underwent MSTS from 2014 to 2017. Demographics, tumour histology and burden, clinical findings, modified Tokuhashi score, operative and blood transfusion (BT) details were recorded. Patients were divided based on BT type: no blood transfusion (NBT) and SBT/ABT. Primary outcomes assessed were overall survival (OS), and tumour progression was evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12 and 24 months, classifying patients with non-progressive and progressive disease.

RESULTS

Seventy-three patients [39:34(M/F)] had mean age of 61 years. Overall median follow-up and survival were 26 and 12 months, respectively. All three groups were comparable for demographics and tumour characteristics. Overall median blood loss was 500 mL, and BT was 1000 mL. Twenty-six (35.6%) patients received SBT, 27 (37.0%) ABT and 20 (27.4%) NBT. Females had lower OS and higher risk of tumour progression. SBT had better OS and reduced risk of tumour progression than ABT group. Total blood loss was not associated with tumour progression. Infective complications other than SSI were significantly (p = 0.027) higher in ABT than NBT/SBT groups.

CONCLUSIONS

Patients of SBT had OS and tumour progression better than ABT/NBT groups. This is the first prospective study to report of SBT in comparison with control groups in MSTS.

COSTS ANALYSIS OF SPINAL COLUMN METASTASES SURGICAL TREATMENT

Introduction

End-of-life cancer treatment is associated with substantial healthcare costs.

Objective

This study aimed to analyze the surgical treatment cost of spinal metastasis and epidural compression patients undergoing surgical treatment.

Methods

A retrospective cost analysis of 81 patients with spinal metastasis and epidural compression undergoing surgical treatment. Cost evaluation was defined in the following categories: medications, laboratory and imaging tests, nursery, recovery room, intensive care unit, surgical procedure, and consigned material. The cost of pain improvement, functional activity, and survival was also evaluated.

Results

The total cost of surgical treatment for 81 patients was $3,604,334.26, and the average value for each patient was $44,497.95. The highest costs were related to implants (41.1%), followed by hospitalization (27.3%) and surgical procedure (19.7%).

Conclusion

The cost of surgical treatment for spinal metastases is one of the most expensive bone complications in cancer patients. The cost of treatment related to outcomes showed differences according to the outcome analyzed. Hospital stay, tests, drugs, and intensive care play an important role in some of the costs related to the specific outcome. Level of Evidence II, Retrospective Study .

Identifying new predictive factors for survival after surgery for spinal metastases: an exploratory in-depth retrospective analysis

OBJECTIVES

In selected patients with symptomatic spinal metastasis from solid tumors, surgery improves quality of life. Since selection is key, inaccurate survival prognostication may result in poor decisions and outcomes. However, most prognostic scores suffer from suboptimal external validation and subsequent mediocre performance. This warrants the ongoing search for factors that better capture the oncological status. This exploratory study aims to identify new preoperative variables that predict survival.

METHODS

A retrospective analysis was conducted on 62 patients from a tertiary care referral center who underwent debulking and/or reconstruction surgery for spinal metastases between 2006 and 2018, and in whom detailed clinical, oncological, surgical and biochemical variables were collected. Univariate and multivariate analyses were performed for overall survival.

RESULTS

Median survival was 13.2 months. Multivariate analysis for overall survival identified that a higher number of organs with metastases, a shorter time to progression on the last line of systemic therapy before surgery (TTPbs), low serum albumin, high alkaline phosphatase, high C-reactive peptide (CRP), presence of brain metastasis and the index spinal level located in the cervical region were independently associated with shorter survival.

CONCLUSION

We confirmed previously known predictors and identified CRP and TTPbs as new variables that were strongly associated with survival. The latter variable may replace primary tumor type, as improved cancer treatments make the primary tumor type less relevant as a predictor. This study is exploratory and its findings need to be validated, preferably in large prospective multicenter studies that are aiming at improving existing models.

Surgery in Acute Metastatic Spinal Cord Compression: Timing and Functional Outcome

Simple Summary

Spinal metastases affect an exceptionally high number of cancer patients and thereby represent a common challenge for healthcare providers. Patients may suffer from debilitating symptoms, including excruciating back pain, immobility and even neurological dysfunction. An exceptionally acute clinical presentation is caused by the compression of the spinal cord through growth of a spinal metastasis within the spinal canal, which may leave the patient with acute spinal cord injury in need of rapid surgical treatment. In clinical practice and science, no true timeframe has yet been defined within which these patients need to undergo surgery, although it is generally understood that their recovery and functional rehabilitation correlate with the time to surgery after symptom onset. In our study, we analyzed a surgically treated cohort of patients with acute spinal cord injury by metastatic compression to investigate the correlation of the timing of surgery with neurological recovery. We were able to identify a subgroup of patients with significantly improved recovery, in whom surgery was initiated within 16 h after admission. Complication rates were not significantly more frequent in this subgroup compared to patients operated on after 16 h. Based on these findings, we conclude that striving for surgery as early as feasible is a warranted strategy in patients with acute neurological deterioration due to metastatic spinal cord compression.

Abstract

Background: Patients with metastatic spinal cord compression (MSCC) may experience long-term functional impairment. It has been established that surgical decompression improves neurological outcomes, but the effect of early surgery remains uncertain. Our objective was to evaluate the impact of early versus late surgery for acute MSCC due to spinal metastases (SM). Methods: We retrospectively reviewed a consecutive cohort of all patients undergoing surgery for SMs at our institution. We determined the prevalence of acute MSCC; the time between acute neurological deterioration as well as between admission and surgery (standard procedure: decompression and instrumentation); and neurological impairment graded by the ASIA scale upon presentation and discharge. Results: We screened 693 patients with surgery for spinal metastasis; 140 patients (21.7%) had acute MSCC, defined as neurological impairment corresponding to ASIA grade D or lower, acquired within 72 h before admission. Non-MSCC patients had surgery for SM-related cauda equina syndrome, radiculopathy and/or spinal instability. Most common locations of the SM in acute MSCC were the thoracic (77.9%) and cervical (10.7%) spine. Per standard of care, acute MSCC patients underwent surgery including decompression and instrumentation, and the median time from admission to surgery was 16 h (interquartile range 10–22 h). Within the group of patients with acute MSCC, those who underwent early surgery (i.e., before the median 16 h) had a significantly higher rate of ASIA improvement by at least one grade at discharge (26.5%) compared to those who had late surgery after 16 h (10.1%; p = 0.024). Except for a significantly higher sepsis rate in the late surgery group, complication rates did not differ between the late and early surgery subgroups. Conclusions: We report data on the largest cohort of patients with MSCC to date. Early surgery is pivotal in acute MSCC, substantially increasing the chance for neurological improvement without increasing complication rates. We found no significant impact when surgery was performed later than 24 h after admission. These findings will provide the framework for a much-needed prospective study. Until then, the treatment strategy should entail the earliest possible surgical intervention.

Spinal metastasis: narrative reviews of the current evidence and treatment modalities

The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.

Characteristics of Patients Undergoing Surgical Treatment for Spinal Metastases From Colorectal Cancer: A Comparison With Non-Small Cell Lung Cancer

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

This study aimed to investigate the prognosis and characteristics of patients undergoing surgical treatment for colorectal cancer (CRC) spinal metastasis. To better understand the characteristics of such patients, their results were compared with those with spinal metastasis from non-small cell lung cancer (NSCLC), as the prognosis of these patients is well-studied.

SUMMARY OF BACKGROUND DATA

CRC commonly metastasizes to the liver or lung, while spinal metastases occur infrequently. The literature contains very few studies evaluating the prognosis of patients with spinal metastases from CRC.

MATERIALS AND METHODS

A consecutive 155 patients who underwent surgical treatment for spinal metastases from CRC (n=35) or NSCLC (n=120) between 2010 and 2018 were included in this study. Data were collected throughout the disease course, including those concerning all cancer-related treatments for both the primary cancer and spinal metastasis. Categorical variables were divided into patient, tumor, and treatment factors, and postoperative survival times were compared between the CRC and NSCLC groups.

RESULTS

The mean interval from cancer diagnosis to spinal metastasis was significantly greater in CRC group (32.5 mo) than in NSCLC group (12.9 mo). Concurrent spinal metastasis was more common in NSCLC group than CRC group (45.0% vs. 17.2%; P=0.003). Visceral metastasis was found more frequently in CRC group than NSCLC group (77.1% vs. 42.5%; P<0.001). The proportion of patients undergoing postoperative systemic treatment was significantly higher in NSCLC group than CRC group (59.2% vs. 20.0%; P<0.001). Median survival time after spine surgery was 4.2 months in CRC group and 5.8 months in NSCLC group (P=0.015).

CONCLUSIONS

The prognosis after surgical treatment for CRC spinal metastasis was poor, and worse than that of NSCLC group. These results can be explained by the later development of spinal metastases and the limited chance of postoperative medical treatment in CRC spinal metastasis.

COMPLICATIONS OF SURGICAL TREATMENT OF SPINAL METASTASES

ABSTRACT Objectives: To evaluate the complications of surgical treatment in a group of patients with spinal metastasis with epidural compression, undergoing surgical treatment. Methods: This is a comparative retrospective study (level of evidence III), which evaluated 96 patients with spinal metastases undergoing surgical treatment. Intra- and postoperative complications were obtained from the patients’ medical records and correlated with the following clinical characteristics: tumor type, tumor location, neurological deficit, age, number of affected vertebrae, Tokuhashi scale, Tomita scale, Karnofsky performance scale, and type of approach. Results: Complications of surgical treatment were observed in 29 (30.20%) patients. Surgical wound infection was the most frequent complication, observed in 15% of patients. Conclusions: Surgical treatment of spinal metastases presents complications in about 30% of patients and their occurrence should be considered in the treatment planning, weighing the risks and benefits for achieving the treatment goals. Level III evidence; Retrospective Study.

Outcomes and survival of spinal metastasis with epidural compression

Objective:

The goal of the study was to retrospectively evaluate the demographics, clinical manifestation, outcomes, treatment result, and survival of patients with spinal metastasis with epidural metastasis who underwent surgical treatment.

Materials and Methods:

A retrospective evaluation of 103 patients with spinal metastasis and epidural compression who underwent surgical treatment between 2009 and 2015 was performed. The recorded parameters selected for the study were general demographic data (gender, age, and educational level) and clinical data (primary tumor, performance status according to Karnofsky score, neurological status according to Frankel scale, pain, surgical treatment outcomes, and patient survival).

Results:

The mean age of the patients was 55.28 ± 15.79 years, and spinal metastasis was more frequent in males (61.7%). The two most frequent tumors were malignant breast cancer (26.21%) and prostate cancer (22.33%). Preoperative pain was presented in 96 (94.12%) patients and improvement was observed in 44 (47.31%) patients. Symptoms of spinal cord compression were the initial clinical manifestation of the primary tumor in 35 (33.98%) patients. Neurological deficit was observed in 66 (64.07%) patients, and improvement was observed in 43 (41.74%) patients. Improvement of functional outcome and pain was observed in 34 (37.38%) patients. The mean survival was 12.26 months. Longer survival (mean 19.13 months) was observed in patients who showed improvement in their ability to walk or kept it preserved (Frankel D or E).

Conclusions:

Surgical treatment of spinal metastasis can improve pain and functional activities. Longer survival was observed in patients that keep or recovery the walking ability.

Minimally Invasive versus Open Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis

Bones are the third most common location for solid tumor metastasis affecting up to 10% of patients with solid tumors. When the spine is involved, thoracic and lumbar vertebrae are frequently affected. Access to spinal lesions can be through minimally invasive surgery (MIS) or traditional open surgery (OS). This study aims to determine which method provides an advantage. Following the PRISMA (Preferred Inventory for Systematic Reviews and Meta-Analysis) guidelines, a systematic review was conducted to identify studies that compare MIS with OS in patients with spinal metastatic disease. Data were analyzed using Review Manager ver. 5.3 (RevMan; Cochrane, London, UK). Ten studies were included. Operative time was similar among groups at −35.23 minutes (95% confidence interval [CI], −73.36 to 2.91 minutes; p=0.07). Intraoperative bleeding was lower in MIS at −562.59 mL (95% CI, −776.97 to −348.20 mL; p<0.00001). OS procedures had higher odds of requiring blood transfusions at 0.26 (95% CI, 0.15 to 0.45; p<0.00001). Both approaches instrumented similar numbers of levels at −0.05 levels (95% CI, −0.75 to 0.66 levels; p=0.89). We observed a decreased need for postoperative bed rest at −1.60 days (95% CI, −2.46 to −0.74 days; p=0.0003), a shorter length of stay at −3.08 days (95% CI, −4.50 to −1.66 days; p=0.001), and decreased odds of complications at 0.60 (95% CI, 0.37 to 0.96; p=0.03) in the MIS group. Both approaches revealed similar reintervention rates at 0.65 (95% CI, 0.15 to 2.84; p=0.57), effective rates of reducing metastasis-related pain at −0.74 (95% CI, −2.41 to 0.94; p=0.39), and comparable scores of the Tokuhashi scale at −0.52 (95% CI, −2.08 to 1.05; p=0.41), Frankel scale at 1.00 (95% CI, 0.60 to 1.68; p=1.0), and American Spinal Injury Association Scale at 0.53 (95% CI, 0.21 to 1.37; p=0.19). MIS appears to provide advantages over OS. Larger and prospective studies should fully detail the role of MIS as a treatment for spine metastasis.

Prognostic scores for survival as decisional support for surgery in spinal metastases: a performance assessment systematic review

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.

Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications

OBJECTIVE

In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD.

METHODS

The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes.

RESULTS

Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18-1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16-1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46-1.98, p < 0.001), with no significant difference in inpatient mortality rates.

CONCLUSIONS

Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.

Comprehensive surgical treatment strategy for spinal metastases

The management of patients with spinal metastases (SM) requires a multidisciplinary team of specialists involved in oncological care. Surgical management has evolved significantly over the recent years, which warrants reevaluation of its role in the oncological treatment concept. Any patient with a SM was screened for study inclusion. We report baseline characteristics, surgical procedures, complication rates, functional status and outcome of a large consecutive cohort undergoing surgical treatment according to an algorithm. 667 patients underwent 989 surgeries with a mean age of 65 years (min/max 20–94) between 2007 and 2018. The primary cancers mostly originated from the prostate (21.7%), breast (15.9%) and lung (10.0%). Surgical treatment consisted of dorsoventral stabilization in 69.5%, decompression without instrumentation in 12.5% and kyphoplasty in 18.0%. Overall survival reached 18.4 months (95% CI 9.8–26.9) and the median KPS increased by 10 within hospital stay. Surgical management of SMs should generally represent the first step of a conclusive treatment algorithm. The need to preserve long-term symptom control and biomechanical stability requires a surgical strategy currently not supported by level I evidence.

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.

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

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.

A COMPARISON OF THE TOMITA AND TOKUHASHI SCORES IN SPINAL METASTASIS

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.

A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.

Vesselplasty using the Mesh-Hold™ bone-filling container for the treatment of pathological vertebral fractures due to osteolytic metastases: A retrospective study

PURPOSE

To evaluate the clinical benefits and complications of vesselplasty using the Mesh-Hold™ bone-filling container in the treatment of vertebral osteolytic fractures.

METHODS

This was a retrospective study of patients with vertebral osteolytic pathological fractures treated by vesselplasty at Sichuan Cancer Hospital between 09/2014 and 01/2018. VAS¹ (Visual analog scale) scores and ODI² (Oswestry disability index) were recorded routinely 1 day preoperative, at 1 day, 1 month, 3 months, 6 months, and 1 year postoperation, and at the last follow-up. V1³ (The of bone cement injection volume) and V2⁴ (vertebral body osteolytic volume) were evaluated, and the R⁵ (ratio) of bone cement filling was obtained according to the V1/V2.

RESULTS

Sixty-three patients were included (105 segments with osteolytic fractures). The amount of bone cement for each vertebra was 2.4-5.2 ml (3.1 ± 0.7 ml). The ratio (R) of bone cement filling was not related to pain relief or functional recovery (all P > 0.05).The VAS scores and ODI at different time points after surgery were decreased compared with before surgery (all P < 0.05). The bone cement leakage rate was 16.2 % (17/105). The follow-up was 4-30 months (mean of 13 ± 6 months). Thirty patients had died by the last follow-up, all from their cancer.

CONCLUSIONS

The Mesh-Hold™ bone-filling container in the treatment of vertebral fractures induced by osteolytic metastases could reduce pain, improve function, and reduce the bone cement leakage rate in the process of vesselplasty.

SPINAL METASTASIS: DIAGNOSIS, TREATMENT AND PROGNOSIS - INTEGRATIVE REVIEW FROM 2012 TO 2017

ABSTRACT Care of the patient with spinal metastasis is challenging. The topic of this article is the treatment and prognosis of spinal metastases, aiming to enumerate and analyze literature that addresses this treatment and prognosis. The methodology used was an integrative review in the Virtual Health Library. Nineteen articles were identified demonstrating that there is research and scientific production in this area. The thematic units and their categories are: treatment decision - prognostic scales or clinical neurological evaluation; types of treatment - minimally invasive and/or traditional; and effectiveness of prognostic scales higher or lower probability of success, which provide insight into the different possibilities of patient evaluation and their applicability in practice. When making the diagnosis, planning the treatment, and establishing a prognosis, the professional must be in sync with current precepts and act based on the objective and subjective characteristics of the patients, such as beliefs and values, which although immeasurable, influence the survival and the effectiveness of treatment. Level of evidence I; Integrative Review.

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

Prediction Accuracy of Common Prognostic Scoring Systems for Metastatic Spine Disease: Results of a Prospective International Multicentre Study of 1469 Patients

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVE

To assess the clinical accuracy of six commonly cited prognostic scoring systems for patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

There are presently several available methods for the estimation of prognosis in metastatic spinal disease, but none are universally accepted by surgeons for clinical use. These scoring systems have not been rigorously tested and validated in large datasets to see if they are reliable enough to inform day-to-day patient management decisions. We tested these scoring systems in a large cohort of patients. A total of 1469 patients were recruited into a secure internet database, and prospectively collected data were analyzed to assess the accuracy of published prognostic scoring systems.

METHODS

We assessed six prognostic scoring systems, described by the first authors Tomita, Tokuhashi, Bauer, van der Linden, Rades, and Bollen. Kaplan-Meier survival estimates were created for different patient subgroups as described in the original publications. Harrell's C-statistic was calculated for the survival estimates, to assess the concordance between estimated and actual survival.

RESULTS

All the prognostic scoring systems tested were able to categorize patients into separate prognostic groups with different overall survivals. However none of the scores were able to achieve "good concordance" as assessed by Harrell's C-statistic. The score of Bollen and colleagues was found to be the most accurate, with a Harrell's C-statistic of 0.66.

CONCLUSION

No prognostic scoring system was found to have a good predictive value. The scores of Bollen and Tomita were the most effective with Harrell's C-statistic of 0.66 and 0.65, respectively. Prognostic scoring systems are calculated using data from previous years, and are subject to inaccuracies as treatments advance in the interim. We suggest that other methods of assessing prognosis should be explored, such as prognostic risk calculation.

LEVEL OF EVIDENCE

3.

Survival, local control, and health-related quality of life in patients with oligometastatic and polymetastatic spinal tumors: A multicenter, international study

BACKGROUND

The treatment of oligometastatic (≤5 metastases) spinal disease has trended toward ablative therapies, yet to the authors' knowledge little is known regarding the prognosis of patients presenting with oligometastatic spinal disease and the value of this approach. The objective of the current study was to compare the survival and clinical outcomes of patients with cancer with oligometastatic spinal disease with those of patients with polymetastatic (>5 metastases) disease.

METHODS

The current study was an international, multicenter, prospective study. Patients who were admitted to a participating spine center with a diagnosis of spinal metastases and who underwent surgical intervention and/or radiotherapy between August 2013 and May 2017 were included. Data collected included demographics, overall survival, local control, and treatment information including surgical, radiotherapy, and systemic therapy details. Health-related quality of life (HRQOL) measures included the EuroQOL 5 dimensions 3-level questionnaire (EQ-5D-3L), the 36-Item Short Form Health Survey (SF-36v2), and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ).

RESULTS

Of the 393 patients included in the current study, 215 presented with oligometastatic disease and 178 presented with polymetastatic disease. A significant survival advantage of 90.1% versus 77.3% at 3 months and 77.0% versus 65.1% at 6 months from the time of treatment was found for patients presenting with oligometastatic disease compared with those with polymetastatic disease. It is important to note that both groups experienced significant improvements in multiple HRQOL measures at 6 months after treatment, with no differences in these outcome measures noted between the 2 groups.

CONCLUSIONS

The treatment of oligometastatic disease appears to offer a significant survival advantage compared with polymetastatic disease, regardless of treatment choice. HRQOL measures were found to improve in both groups, demonstrating a palliative benefit for all treated patients.

Management - spinal metastases

Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.