Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases

OBJECTIVE Frailty—the state defined by decreased physiological reserve and increased vulnerability to physiological stress—is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients. METHODS A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of ≥ 1 postoperative complication. RESULTS In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced ≥ 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06–2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29–2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74–4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36–2.11, p < 0.01), and ≥ 1 complication (OR 1.95 per point, 95% CI 1.23–3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12–1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of ≥ 1 postoperative complication (OR 1.45 per point, 95% CI 1.22–1.72, p < 0.01). CONCLUSIONS Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.

Early Ambulation Training as Impairment-Driven Rehabilitation in Cancer Patients with Cervical Spine Metastases After Palliative Spine Surgery

Background Cervical spine metastasis worsens the quality of life (QOL) of patients with cancer. While the beneficial effects of surgery have been reported, the detailed course of functional recovery remains unclear, especially in the acute phase of rehabilitation. We previously reported on impairment-driven rehabilitation in patients with thoracic or lumbar level metastases. The present study assessed the effects of an impairment-driven strategy on the early recovery of ambulatory function in patients with cervical spine metastasis. Methods We retrospectively reviewed 13 consecutive patients with cervical neoplastic spinal compression. The patients were those whose primary impairment with spinal instability identified by a multidisciplinary tumor board who underwent palliative spine surgery. In addition, we examined neurological deficits; ambulation status; pathological fracture, collapse, and postoperative implant failure progress; and Barthel Index (BI). Results The average duration of ambulation was 3.75 ± 3.92 days after surgery. One case showed collapse and two showed progressions of paralysis. However, all patients had early ambulation after surgery, except for one patient who developed postoperative cerebral infarction. The BI scores showed an improving tendency; however, the difference before and after rehabilitation was not statistically significant. Conclusions We reviewed the recovery course of ambulation in patients with cervical spine metastases who underwent impairment-driven rehabilitation. Combined with surgery and early mobilization, this strategy may improve the QOL of patients with cancer and cervical spine metastasis.

Palliative radiation treatment used for multiple purposes in a single irradiation field

In this case report, radiation therapy was performed for bilateral hydronephrosis developed during multiple bone metastases of breast cancer and ileus due to peritoneal dissemination. The patient’s preirradiation creatinine level was 8.2 mg/dL, which decreased by the fourth day after starting irradiation therapy. Creatinine level ultimately decreased to 0.6 mg/dL. Pain due to lumbar spine metastasis alleviated and ileus was resolved, allowing the patient to live at home for approximately 5 weeks. The effect of radiotherapy for bilateral hydronephrosis and gastrointestinal obstruction was rapid and good. Palliative radiation treatment can be used for multiple purposes, and in the present patient, we were able to prolong the vital prognosis.

DECOMPRESSIVE LAMINECTOMY IN PATIENTS WITH SPINE METASTASIS

The aim is to present the experience of treating patients with spinal metastases, who underwent decompression laminectomy with posterior stabilization.Material and methods. The study included 326 patients with spine metastasis, who underwent posterior thoracic laminectomy (199, 61 %) and lumbar laminectomy (127, 39 %). The mean age of patients was 63 (range, 29–78 years). There were 91 (28 %) males and 235 (72 %) females. Breast cancer was diagnosed in 137 (42 %) patients, kidney cancer in 69 (21 %) patients, prostate cancer in 39 (12 %) patients, lung cancer in 19 (6 %) patients, colorectal cancer in 16 (5 %) patients, thyroid cancer in 13 (4 %) patients, and the remaining 10 % of patients accounted for other more rare forms of malignanciesResults. The mean time of surgery was 95 min. (55–245 min.). Intraoperative blood loss volume was 245 ml (150–3200 ml). The mean hospital stay was 8 days (5–20 days). The pain intensity according to vas reduced in 160 (49 %) patients. According to the frankel classification system, neurological status improved in 85 (26 %) patients. Neurological deterioration was observed in 7 (2 %) patients. Intra-and early-/late postoperative complications were observed in 66 (20 %) patients. Traumatic dural tears occurred in 16 (5 %) patients. Infection rate was 4.5 %. Cardiac complications were observed in 12 (3.5 %) patients. Postoperative hematoma was revealed in 7 (2.4 %) patients.Conclusion. The results obtained indicate that patients with metastatic spine disease represent a difficult group of patients for surgical treatment because of a high risk of developing postoperative complications, the most serious of which are neurological disorders with paraplegia and other fatal outcomes. Nevertheless, modern surgical techniques can improve the quality of life of these patients, improve psycho-emotional abilities and avoid disability.

Surgical outcomes and risk factors for poor outcomes in patients with cervical spine metastasis: a prospective study

Background Few studies have addressed the impact of palliative surgery for cervical spine metastasis on patients’ performance status (PS) and quality of life (QOL). We investigated the surgical outcomes of patients with cervical spine metastasis and the risk factors for a poor outcome with a focus on the PS and QOL. Methods We prospectively analyzed patients with cervical spine metastasis who underwent palliative surgery from 2013 to 2018. The Eastern Cooperative Oncology Group PS (ECOGPS) and EuroQol 5-Dimension (EQ5D) score were assessed at study enrollment and 1, 3, and 6 months postoperatively. Neurological function was evaluated with Frankel grading. Univariate and multivariate analyses were performed to identify the risk factors for a poor surgical outcome, defined as no improvement or deterioration after improvement of the ECOGPS or EQ5D score within 3 months. Results Forty-six patients (mean age, 67.5 ± 11.7 years) were enrolled. Twelve postoperative complications occurred in 11 (23.9%) patients. The median ECOGPS improved from PS3 at study enrolment to PS2 at 1 month and PS1 at 3 and 6 months postoperatively. The mean EQ5D score improved from 0.085 ± 0.487 at study enrolment to 0.658 ± 0.356 at 1 month and 0.753 ± 0.312 at 3 months. A poor outcome was observed in 18 (39.1%) patients. The univariate analysis showed that variables with a P value of < 0.10 were sex (male), the revised Tokuhashi score, the new Katagiri score, the level of the main lesion, and the Frankel grade at baseline. The multivariate analysis identified the level of the main lesion (cervicothoracic junction) as the significant risk factor (odds ratio, 5.00; P = 0.025). Conclusions Palliative surgery for cervical spine metastasis improved the PS and QOL, but a cervicothoracic junction lesion could be a risk factor for a poor outcome.

Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance

OBJECTIVE Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM. METHODS It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017. RESULTS In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita’s prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35–0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64–0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54–0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen’s kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen’s kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a “slight” rate of agreement (weighted Cohen’s kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival. CONCLUSIONS The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.