Changes in Spinal Instability After Conventional Radiotherapy for Painful Vertebral Bone Metastases

OBJECTIVE

Precise assessment of spinal instability is critical before and after radiotherapy (RT) for evaluating the effectiveness of RT. Therefore, we retrospectively evaluated the efficacy of RT in spinal instability over a period of 6 months after RT, utilizing the spinal instability neoplastic score (SINS) in patients with painful spinal metastasis. We retrospectively evaluated 108 patients who received RT for painful vertebral metastasis in our institution. Mechanical pain at metastatic vertebrae, radiological responses of irradiated vertebrae, and spinal instability were assessed. Follow-up assessments were done at the start of and at intervals of 1, 2, 3, 4, and 6 months after RT, with the pain disappearing in 67%, 85%, 93%, 97%, and 100% of the patients, respectively. The median SINS were 8, 6, 6, 5, 5, and 4 at the beginning and after 1, 2, 3, 4, and 6 months of RT, respectively. Multivariate analysis revealed that posterolateral involvement of spinal elements (PLISE) was the only risk factor for continuous potentially unstable/unstable spine at 1 month. In conclusion, there was improvement of pain, and recalcification results in regaining spinal stability over time after RT although vertebral body collapse and malalignment occur in some irradiated vertebrae. Clinicians should pay attention to PLISE in predicting continuous potentially unstable/unstable spine.

A precision-based exercise program for patients with multiple myeloma

OBJECTIVES

Aim of this study was to retrospectively evaluate an interdisciplinary consultation followed by a precision-based exercise program (PEP) for myeloma patients with stable and unstable bone lesions.

METHODS

Data of myeloma patients (n = 100) who received a PEP according to an orthopedic evaluation were analyzed. Bone stability was assessed by established scoring systems (Spinal Instability Neoplastic Score [SINS], Mirels' score). All patients with stable and unstable osteolyses received a PEP and n = 91 were contacted for a follow-up interview.

RESULTS

In 60% of patients at least one osteolysis of the spine was considered potentially unstable or unstable. Following consultation, the number of patients performing resistance training could be significantly increased (≥2 sessions/week, 55%). Musculoskeletal pain was reported frequently. At the follow-up interview, 75% of patients who performed PEP stated that painful symptoms could be effectively alleviated by exercise. Moreover, only patients who exercised regularly discontinued pain medication. No injuries were reported in association with PEP.

CONCLUSION

We were able to demonstrate that individualized resistance training is implementable and safe for myeloma patients. By means of a PEP, patients' self-efficacy in managing musculoskeletal pain was enhanced and pain medication could be reduced.

Risk Factors for Radiotherapy Failure in the Treatment of Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To build a predictive model for risk factors for failure of radiation therapy, hypothesizing a higher SINS would correlate with failure.

METHODS

Patients with spinal metastasis being treated with radiation at a tertiary care academic center between September 2014 and October 2018 were identified. The primary outcome measure was radiation therapy failure as defined by persistent pain, need for re-irradiation, or surgical intervention. Risk factors were primary tumor type, Karnofsky and ECOG scores, time to treatment, biologically effective dose (BED) calculations using α/β ratio = 10, and radiation modality. A logistic regression was used to construct a prediction model for radiation therapy failure.

RESULTS

One hundred and seventy patients were included. Median follow up was 91.5 days. Forty-three patients failed radiation therapy. Of those patients, 10 required repeat radiation and 7 underwent surgery. Thirty-six patients reported no pain relief, including some that required re-irradiation and surgery. Total SINS score for those who failed reduction therapy was <7 for 27 patients (62.8%), between 7-12 for 14 patients (32.6%), and >12 for 2 patients (4.6%). In the final prediction model, BED (OR .451 for BED > 43 compared to BED ≤ 43; P = .174), Karnofksy score (OR .736 for every 10 unit increase in Karnofksy score; P = .008), and gender (OR 2.147 for male compared to female; P = .053) are associated with risk of radiation failure (AUC .695). A statistically significant association between SINS score and radiation therapy failure was not found.

CONCLUSIONS

In the multivariable model, BED ≤ 43, lower Karnofksy score, and male gender are predictive for radiotherapy failure. SINS score was among the candidate risk factors included in multivariable model building procedure, but it was not selected in the final model.

LEVEL OF EVIDENCE

Prognostic level III.

Management of extranodal lymphoma of the spine: a study of 30 patients

Extranodal lymphoma of the spine is often a late manifestation of systemic disease, and may result in symptoms of pain, neurologic compromise or spinal instability. Symptomatic relief is generally achieved by radiotherapy alone, but is not sufficient in addressing spinal instability. The indications for surgery remain controversial, but may be required for spinal stabilization, or refractory disease. Currently, there is a lack of studies that compare the indications and clinical outcomes of patients receiving surgical and nonsurgical management of spinal extranodal lymphoma. Medical records of 30 patients seen from March 2006 to August 2015, with histologically confirmed spinal lymphoma, were retrospectively reviewed. Demographic information, clinical factors, imaging, treatment and clinical outcomes were recorded. 19 patients were treated surgically and 11 nonsurgically (i.e., chemotherapy, radiation or combination). Surgery was performed for emergent neurological deterioration, mechanical stabilization, refractoriness to medical management or to perform an open biopsy for pathological diagnosis. Among those treated surgically, significantly fewer patients could carry on normal activities (KPS <70) at baseline, compared with those treated nonsurgically. However, there were no significant differences regarding pain medication use, functional status at 1 year, or mean survival (87.6 months) between groups. Surgery for extranodal lymphoma may be required in specific cases, resulting in favorable and similar outcomes compared with nonsurgical management.

Impact of the Spinal Instability Neoplastic Score on Surgical Referral Patterns and Outcomes

Background

The Spinal Instability Neoplastic Score (sins) was developed to identify patients with spinal metastases who may benefit from surgical consultation. We aimed to assess the distribution of sins in a population-based cohort of patients undergoing palliative spine radiotherapy (rt) and referral rates to spinal surgery pre-rt. Secondary outcomes included referral to a spine surgeon post-rt, overall survival, maintenance of ambulation, need for re-intervention, and presence of spinal adverse events.

Methods

We retrospectively reviewed ct simulation scans and charts of consecutive patients receiving palliative spine rt between 2012 and 2013. Data were analyzed using Student's t-test, Chi-squared, Fisher's exact, and Kaplan-Meier log-rank tests. Patients were stratified into low (<7) and high (≥7) sins groups.

Results

We included 195 patients with a follow-up of 6.1 months. The median sins was 7. The score was 0 to 6 (low, no referral recommended), 7 to 12 (intermediate, consider referral), and 13 to 18 (high, referral suggested) in 34%, 59%, and 7% of patients, respectively. Eleven patients had pre-rt referral to spine surgery, with a surgery performed in 0 of 1 patient with sins 0 to 6, 1 of 7 with sins 7 to 12, and 1 of 3 with sins 13 to 18. Seven patients were referred to a surgeon post-rt with salvage surgery performed in two of those patients. Primary and secondary outcomes did not differ between low and high sins groups.

Conclusion

Higher sins was associated with pre-rt referral to a spine surgeon, but most patients with high sins were not referred. Higher sins was not associated with shorter survival or worse outcome following rt.

Is there a correlation between the spinal instability neoplastic score and mechanical pain in patients with metastatic spinal cord compression? A prospective cohort study

INTRODUCTION

The decision for selecting patients for surgical treatment of metastatic spinal cord compression (MSCC) is challenging even for experienced surgeons. Recently, the spinal instability neoplastic score (SINS) has been proposed to help surgeons in the evaluation of spinal stability in the setting of spinal metastases. This study aimed to evaluate the correlation between SINS and preoperative visual analog scale (VAS), as well as the pre- and post-operative association of the VAS and neurological function.

METHODS

A prospective cohort study was conducted in a tertiary referral cancer center. Seventy-nine patients with MSCC were surgically treated from June 2012 to March 2015. Pain status before and after surgery was assessed using VAS score, and neurological status was evaluated using the American Spine Injury Association Impairment Scale (AIS) before and after surgery. Pain was classified as VAS (0-4) none or mild pain; VAS (5-8) moderate pain; and VAS (9-10) as severe pain. Neurological function was scored as AIS A: Complete deficits, AIS B-D: Incomplete deficits, AIS E: Neurologically intact. SINS degrees were classified as 0-6-stable; 7-12 potentially unstable, and 13-18-unstable. Spearman's correlation coefficient test was utilized for correlation between pain and SINS; Chi-square association test was utilized for evaluating pre- and post-operative pain and AIS, as well as the association between SINS and tumor types.

RESULTS

A higher SINS correlates with severe mechanical pain preoperatively (ρ = 0.38, P = 0.001); surgical procedure improved neurological function (P = 0.0001), and decrease pain (P = 0.84). Finally, a higher SINS was also associated with osteolytic tumors (P = 0.03).

CONCLUSIONS

The SINS correlates with mechanical pain. Surgery provides a significant improvement in pain and neurological status, especially in patients who presented higher SINS scores and some degree of preoperative neurological function.