International Variability in Spinal Metastasis Treatment: A Survey of the AO Spine Community

Study Design International survey. Objectives To assess variability in the treatment practices for spinal metastases as a function of practice setting, surgical specialty, and fellowship training among an international group of spine surgeons. Methods An anonymous internet-based survey was disseminated to the AO Spine membership. The questionnaire contained items on practice settings, fellowship training, indications used for spinal metastasis surgery, surgical strategies, multidisciplinary team use, and postoperative follow-up priorities and practice. Results 341 gave complete responses to the survey with 76.3% identifying spinal oncology as a practice focus and 95.6% treating spinal metastases. 80% use the Spinal Instability Neoplastic Score (SINS) to guide instrumentation decision-making and 60.7% recruit multidisciplinary teams for some or all cases. Priorities for postoperative follow-up are adjuvant radiotherapy (80.9%) and systemic therapy (74.8%). Most schedule first follow-up within 6 weeks of surgery (62.2%). Significant response heterogeneity was seen when stratifying by practice in an academic or university-affiliated center, practice in a cancer center, completion of a spine oncology fellowship, and self-identification as a tumor specialist. Respondents belonging to any of these categories were more likely to utilize SINS ( P < .01-.02), recruit assistance from plastic surgeons (all P < .01), and incorporate radiation oncologists in postoperative care ( P < .01-.03). Conclusions The largest variability in practice strategies is based upon practice setting, spine tumor specialization, and completion of a spine oncology fellowship. These respondents were more likely to use evidenced-based practices. However, the response variability indicates the need for consensus building, particularly for postoperative spine metastasis care pathways and multidisciplinary team use.

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Evaluation of predictive factors of vertebral compression fracture after conventional palliative radiotherapy for spinal metastasis from colorectal cancer

Journal of Neurosurgery Spine ◽

10.3171/2017.6.spine17282 ◽

2018 ◽

Vol 28 (3) ◽

pp. 333-340 ◽

Cited By ~ 4

Author(s):

Jeongshim Lee ◽

Woo Joong Rhee ◽

Jee Suk Chang ◽

Sei Kyung Chang ◽

Woong Sub Koom

Keyword(s):

Colorectal Cancer ◽

Vertebral Compression Fracture ◽

De Novo ◽

Spinal Metastasis ◽

Multivariable Analysis ◽

Spinal Metastases ◽

Compression Fracture ◽

Palliative Radiotherapy ◽

Spinal Instability ◽

Spinal Segments

OBJECTIVEDelayed consequences of spinal radiotherapy (RT), including vertebral compression fracture (VCF), are critical complications. However, the predisposing factors that contribute to VCF after conventional RT are unclear. The aim of this study was to assess the incidence of VCF and to determine the predictors of VCF following conventional spinal RT specific to colorectal cancer (CRC).METHODSThe authors retrospectively reviewed 237 spinal segments (147 metastatic and 90 nonmetastatic) in 53 patients with CRC who underwent RT with a median total dose of 30 Gy in 10 fractions between January 2007 and December 2014. The primary end point was the development of a VCF following RT, either de novo VCF or the progression of a baseline VCF. VCFs were assessed using the spinal instability neoplastic score (SINS) criteria.RESULTSAmong all 237 spinal segments, 22 VCFs (9.3%) were observed following RT, including 13 de novo and 9 progressive fractures, and the median time to VCF was 4 months. All VCFs developed in metastatic spines. Among 147 metastatic spinal segments, 22 fractures were observed, with a 12-month cumulative incidence of VCF of 14.8%. Results of multivariable analysis indicated sex (p = 0.023) and SINS class II/III (p < 0.001) as risk factors related to development of a VCF in metastatic spinal segments. Among the SINS criteria, a lytic tumor and the presence of a baseline VCF were identified as predictors of VCF in metastatic spinal segments.CONCLUSIONSIn osteolytic or mixed lesions that were predominant in spinal metastases of CRC, the incidence of VCF was not negligible, even in patients treated with conventional spinal RT. This was especially evident in patients with spinal metastases with a SINS score ≥ 7. Presence of a baseline VCF after spinal RT is a predictor of VCF development and should be observed carefully.

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Multiple myeloma of the cervical spine: treatment strategies for pain and spinal instability

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.5.2.140 ◽

2006 ◽

Vol 5 (2) ◽

pp. 140-145 ◽

Cited By ~ 27

Author(s):

Ganesh Rao ◽

Chul S. Ha ◽

Indro Chakrabarti ◽

Iman Feiz-Erfan ◽

Ehud Mendel ◽

...

Keyword(s):

Multiple Myeloma ◽

Cervical Spine ◽

Treatment Strategies ◽

Retrospective Chart Review ◽

External Beam Radiation ◽

Cancer Center ◽

Spinal Instability ◽

External Beam ◽

Beam Radiation

Object Metastases of multiple myeloma often occur in the cervical spine. These metastases may cause pain and associated spinal instability. The authors report the results of radiotherapy and surgical treatment for myeloma involving the cervical spine. The results of radiation therapy for multiple myeloma metastases to the cervical spine that cause clinical or radiographically documented instability have not been reported previously. Methods A retrospective chart review of patients with multiple myeloma metastases to the cervical spine was undertaken. Between 1993 and 2005, 35 patients were treated with external-beam radiation and/or surgical stabilization at the University of Texas M. D. Anderson Cancer Center in Houston, Texas. Nineteen of 20 patients with sufficient follow-up data experienced resolution of their pain when treated with radiation without surgical intervention. Twenty-three patients had evidence of spinal instability on radiographic images; 15 of these were treated with radiation alone. Of these, 10 had sufficient follow-up data, and none showed any clinical progression of instability. Radiographic follow-up images demonstrated an arrest of further progression of instability and, in some cases, healing of pathological fractures by means of radiation alone. Conclusions The results of this series suggest that, in selected cases, external-beam radiation for multiple myeloma metastases to the cervical spine is an effective palliative treatment, even in cases involving clinical or radiographically documented instability.

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Changes in Spinal Instability After Combined Therapy of Conventional Radiotherapy and Bone Modifying Agents for Painful Vertebral Bone Metastases

10.21203/rs.3.rs-258203/v1 ◽

2021 ◽

Author(s):

Eiji Nakata ◽

Shinsuke Sugihara ◽

Yoshifumi Sugawara ◽

Ryuichi Nakahara ◽

Shouta Takihira ◽

...

Keyword(s):

Combined Therapy ◽

Spinal Metastases ◽

Spinal Instability ◽

Vertebral Metastases ◽

Conventional Radiotherapy ◽

Potential Risk Factors ◽

The Difference ◽

Over Time ◽

Selection Of

Abstract Precise assessment of spinal instability is critical at the beginning and after radiotherapy for selection of the treatment and evaluating the effectiveness of radiotherapy. We investigated changes of spinal instability after radiotherapy and examined potential risk factors for the difference of the outcome of spinal instability for painful spinal metastases. We evaluated 81 patients who received radiotherapy for painful vertebral metastases in our institution between 2012 and 2016. The pain at the vertebrae was assessed. Radiological responses of irradiated vertebrae were assessed by computed tomography. Spinal instability was assessed by Spinal Instability Neoplastic Score (SINS). Follow-up assessments were done at the start of radiotherapy and at 1, 2, 3, 4, and 6 months after radiotherapy. At each of one to six months, pain disappeared in 62%, 84%, 93%, 98%, and 100% of patients. The median SINS were 8, 7, 6, 5, 5, and 4 at the beginning of radiotherapy and after 1, 2, 3, 4, and 6 months, respectively, which significantly decreased over time (P < 0.001). Multivariate analysis revealed that PLISE was the only risk factor for spinal instability at one month. In conclusion, spinal instability significantly improved over time after radiotherapy. Clinicians should take attention to PLISE in the radiotherapy of vertebral metastases.

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A novel MRI-based score assessing trabecular bone quality to predict vertebral compression fractures in patients with spinal metastasis

Journal of Neurosurgery Spine ◽

10.3171/2019.9.spine19954 ◽

2020 ◽

Vol 32 (4) ◽

pp. 499-506 ◽

Cited By ~ 2

Author(s):

Jeff Ehresman ◽

Andrew Schilling ◽

Zach Pennington ◽

Chengcheng Gui ◽

Xuguang Chen ◽

...

Keyword(s):

Bone Quality ◽

Signal Intensity ◽

Scoring System ◽

Spinal Metastasis ◽

Multivariable Analysis ◽

Spinal Metastases ◽

Vertebral Compression Fractures ◽

Spinal Instability ◽

The Novel ◽

Compression Fractures

OBJECTIVEVertebral compression fractures (VCFs) in patients with spinal metastasis can lead to destabilization and often carry a high risk profile. It is therefore important to have tools that enable providers to predict the occurrence of new VCFs. The most widely used tool for bone quality assessment, dual-energy x-ray absorptiometry (DXA), is not often available at a patient’s initial presentation and has limited sensitivity. While the Spinal Instability Neoplastic Score (SINS) has been associated with VCFs, it does not take patients’ baseline bone quality into consideration. To address this, the authors sought to develop an MRI-based scoring system to estimate trabecular vertebral bone quality (VBQ) and to assess this system’s ability to predict the occurrence of new VCFs in patients with spinal metastasis.METHODSCases of adult patients with a diagnosis of spinal metastasis, who had undergone stereotactic body radiation therapy (SBRT) to the spine or neurosurgical intervention at a single institution between 2012 and 2019, were retrospectively reviewed. The novel VBQ score was calculated for each patient by dividing the median signal intensity of the L1–4 vertebral bodies by the signal intensity of cerebrospinal fluid (CSF). Multivariable logistic regression analysis was used to identify associations of demographic, clinical, and radiological data with new VCFs.RESULTSAmong the 105 patients included in this study, 56 patients received a diagnosis of a new VCF and 49 did not. On univariable analysis, the factors associated with new VCFs were smoking status, steroid use longer than 3 months, the SINS, and the novel scoring system—the VBQ score. On multivariable analysis, only the SINS and VBQ score were significant predictors of new VCFs and, when combined, had a predictive accuracy of 89%.CONCLUSIONSAs a measure of bone quality, the novel VBQ score significantly predicted the occurrence of new VCFs in patients with spinal metastases independent of the SINS. This suggests that baseline bone quality is a crucial factor that requires assessment when evaluating these patients’ conditions and that the VBQ score is a novel and simple MRI-based measure to accomplish this.

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Management of atlantoaxial metastases with posterior occipitocervical stabilization

Journal of Neurosurgery Spine ◽

10.3171/spi.2003.98.2.0165 ◽

2003 ◽

Vol 98 (2) ◽

pp. 165-170 ◽

Cited By ~ 11

Author(s):

Daryl R. Fourney ◽

Julie E. York ◽

Zvi R. Cohen ◽

Dima Suki ◽

Laurence D. Rhines ◽

...

Keyword(s):

Tumor Resection ◽

Spinal Metastases ◽

Neurological Deficits ◽

Rank Test ◽

Cancer Center ◽

Content Type ◽

University Of Texas ◽

Signed Rank Test ◽

Fine Print

Object. The treatment of atlantoaxial spinal metastases is complicated by the region's unique biomechanical and anatomical characteristics. Patients most frequently present with pain secondary to instability; neurological deficits are rare. Recently, some authors have performed anterior approaches (transoral or extraoral) for resection of upper cervical metastases. The authors review their experience with a surgical strategy that emphasizes posterior stabilization of the spine and avoidance of poorly tolerated external orthoses such as the rigid cervical collar or halo vest. Methods. The authors performed a retrospective review of 19 consecutively treated patients with C-1 or C-2 metastases who underwent surgery at The University of Texas M. D. Anderson Cancer Center between 1994 and 2001. Visual analog pain scores were reduced at 1 and 3 months (p < 0.005, Wilcoxon signed-rank test); however, evaluation of pain at 6 months and 1 year was limited by the remaining number of surviving patients. Analgesic medication consumption was unchanged. There were no cases of neurological decline or sudden death secondary to residual or recurrent atlantoaxial disease during the follow-up period. One patient underwent revision of hardware at 11 months. The mean follow-up period was 8 months (range 1–32 months). Median survival determined by Kaplan—Meier analysis was 6.1 months (95% confidence interval 2.99–9.21). Conclusions. Occipitocervical stabilization provided durable pain relief and preservation of ambulatory status over the remaining life span of patients. Because of the palliative goals of surgery, the authors have not found an indication for anterior-approach tumor resection in these patients. Successful stabilization obviates the need for an external orthosis.

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

Current Oncology ◽

10.3747/co.25.3835 ◽

2018 ◽

Vol 25 (1) ◽

pp. 53 ◽

Cited By ~ 2

Author(s):

M. Dosani ◽

S. Lucas ◽

J. Wong ◽

L. Weir ◽

S. Lomas ◽

...

Keyword(s):

Spinal Metastases ◽

Population Based ◽

Spinal Instability ◽

Kaplan Meier ◽

Chi Squared ◽

Ct Simulation ◽

Secondary Outcomes ◽

Student’S T ◽

Spine Surgeon

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.

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Frequency of symptomatic vertebral body compression fractures requiring intervention following single-fraction stereotactic radiosurgery for spinal metastases

Neurosurgical FOCUS ◽

10.3171/2016.10.focus16359 ◽

2017 ◽

Vol 42 (1) ◽

pp. E8 ◽

Cited By ~ 26

Author(s):

Michael S. Virk ◽

James E. Han ◽

Anne S. Reiner ◽

Lily A. McLaughlin ◽

Daniel M. Sciubba ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Vertebral Body ◽

Cumulative Incidence ◽

Spinal Metastases ◽

Intensity Modulated Radiation Therapy ◽

Cancer Center ◽

Spinal Instability ◽

Mechanical Instability ◽

Single Fraction ◽

Compression Fractures

OBJECTIVE The purpose of this study was to determine the rate of symptomatic vertebral body compression fractures (VCFs) requiring kyphoplasty or surgery in patients treated with 24-Gy single-fraction stereotactic radiosurgery (SRS). METHODS This retrospective analysis included all patients who had been treated with 24-Gy, single-fraction, image-guided intensity-modulated radiation therapy for histologically confirmed solid tumor metastases over an 8-year period (2005–2013) at Memorial Sloan Kettering Cancer Center. Charts and imaging studies were reviewed for post-SRS kyphoplasty or surgery for mechanical instability. A Spinal Instability Neoplastic Score (SINS) was calculated for each patient both at the time of SRS and at the time of intervention for VCF. RESULTS Three hundred twenty-three patients who had undergone single-fraction SRS between C-1 and L-5 were included in this analysis. The cumulative incidence of VCF 5 years after SRS was 7.2% (95% CI 4.1–10.2), whereas that of death following SRS at the same time point was 82.5% (95% CI 77.5–87.4). Twenty-six patients with 36 SRS-treated levels progressed to symptomatic VCF requiring treatment with kyphoplasty (6 patients), surgery (10 patients), or both (10 patients). The median time to symptomatic VCF was 13 months. Seven patients developed VCF at 11 levels adjacent to the SRS-treated level. Fractured levels had no evidence of tumor progression. The median SINS changed from 6.5 at SRS (interquartile range [IQR] 4.3–8.8) to 11.5 at stabilization (IQR 9–13). In patients without prior stabilization at the level of SRS, there was an association between the SINS and the time to fracture. CONCLUSIONS Five years after ablative single-fraction SRS to spinal lesions, the cumulative incidence of symptomatic VCF at the treated level without tumor recurrence was 7.2%. Higher SINSs at the time of SRS correlated with earlier fractures.

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Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa079 ◽

2020 ◽

Vol 77 (12) ◽

pp. 958-965

Author(s):

Amber Lanae Martirosov ◽

Zachary Ryan Smith ◽

Laura Hencken ◽

Nancy C MacDonald ◽

Kristin Griebe ◽

...

Keyword(s):

Critical Care ◽

Pulmonary Arterial Hypertension ◽

Arterial Hypertension ◽

Ambulatory Care ◽

Multidisciplinary Team ◽

Transitions Of Care ◽

Multidisciplinary Teams ◽

Medication Access ◽

Pulmonary Arterial

Abstract Purpose The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. Summary Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. Conclusion Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers.

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P.129 Patterns of spinal metastatic disease and mechanical instability: a retrospective correlation with tumor histology

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.228 ◽

2016 ◽

Vol 43 (S2) ◽

pp. S50-S50

Author(s):

A Dakson ◽

E Leck ◽

M Butler ◽

G Thibault-Halman ◽

S Christie

Keyword(s):

Metastatic Disease ◽

Spinal Metastasis ◽

Spinal Metastases ◽

Scoring Systems ◽

Epidemiological Data ◽

Spinal Instability ◽

Mechanical Instability ◽

Imaging Studies ◽

Tumor Histology ◽

Multiple Metastases

Background: This study aims to provide epidemiological data concerning spinal instability and patterns of metastatic invasion of the spine based on tumor histology. Methods: We allocated 285 patients with spinal metastatic disease through a retrospective review. SINS was calculated using good-quality computed tomography (CT) imaging studies. Spinal metastases were also grouped into intracompartmental, extracompartmental or multiple metastases. Results: Esophageal cancer was the least likely to be associated with instability with about 64% of cases being stable. The highest rate of instability scores was observed in breast carcinoma with 18% of cases graded as unstable. Renal cell carcinoma was associated with lytic spinal metastases whereas blastic metastases mostly occurred in prostate carcinoma (P<0.001). Whereas 68.1% of cases represented multiple metastases, the remainder was associated with either intracompartmental (13.3%) or extracompartmental (18.6%) disease. The highest degrees of spinal instability (intermediate and unstable categories) were associated with extra-compartmental metastatic disease (P<0.001). Conclusions: This study sheds light on the patterns of spinal metastatic disease and mechanical instability on the basis of tumor histology, utilizing standardized scoring systems. The utilization of such scoring systems allows for a standardized approach towards description and analysis of spinal metastasis facilitating clinical research in this avenue.

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Outcomes of Surgical Decompression for Spinal Metastases From Gynecological Cancers: A Retrospective Cohort Study

Iranian Journal of Neurosurgery ◽

10.32598/irjns.7.1.5 ◽

2021 ◽

Vol 7 (1) ◽

pp. 37-48

Author(s):

Luiz Alves Vieira Netto ◽

◽

Luís Felipe Araújo Peres ◽

Nayara Matos Pereira ◽

Alice Jardim Zaccariotti1 ◽

...

Keyword(s):

Spinal Cord ◽

Overall Survival ◽

Spinal Injury ◽

Spinal Metastasis ◽

Gynecological Cancer ◽

Spinal Metastases ◽

Decompressive Surgery ◽

Neurological Deficits ◽

Spinal Instability ◽

Spinal Stability

Background and Aim: Gynecological cancer is one of the most common types of cancer worldwide. Nonetheless, spinal metastasis from gynecological cancer is scarcely reported in the literature. In cases of spinal cord compression, the standard treatment is a decompressive surgery followed by radiotherapy treatment for selected patients. This study aimed to report the overall survival and surgical results in patients presenting with gynecological spinal metastases who underwent spinal cord/nerve root decompression and stabilization. Methods and Materials/Patients: A total of 18 patients were included in this study. The surgical procedures were performed from 2012 to 2019. The evaluation of neurological status, spinal stability, and pain were performed using the American Spinal Injury Association Impairment Scale (ASIA), Spinal Instability Neoplastic Score (SINS), and Visual Analogue Scale (VAS), respectively. Results: The lumbar spine was the most affected location (n=30; 50.0%). Regarding the preoperative neurological deficits, 16 cases (n=16; 88.9%) presented ASIA graded A–D before the surgery, being reduced to five (n=5; 27.8%) after the procedures. The pain level means (pre-and postoperative) were 9.39±0.79 and 2.28±1.44. The overall median survival was 6.1 months (95% Confidence Interval [CI] of 1.10–11.13 months). The mean survival of ambulatory and non-ambulatory patients before the surgery was 7.36 months and 3.2 months, respectively (P=0.007 – Log-rank Mantel–Cox). Conclusion: Decompressive surgery and stabilization promote mechanical pain relief, spinal stability, an improvement of neurological function, and indirectly improving quality of life, despite a dismal overall survival of patients who present with metastatic spinal compression disease.

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