Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment

Restricted access

OBJECTIVE

Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes.

METHODS

In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N − 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model.

RESULTS

Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy.

CONCLUSIONS

At the authors’ institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.

ABBREVIATIONS MFRT = multiple-fraction radiation therapy; OIS = Oncology Information System; PI = potential instability; SFRT = single-fraction radiation therapy; SINS = Spinal Instability Neoplastic Score; SRT = stereotactic radiotherapy.
Article Information

Contributor Notes

Correspondence Patricia Zadnik Sullivan: University of Pennsylvania, Philadelphia, PA. patricia.zadnik@pennmedicine.upenn.edu.INCLUDE WHEN CITING Published online February 14, 2020; DOI: 10.3171/2019.11.SPINE19775.Disclosures Dr. Saifi has direct stock ownership in Vertera/NuVasive. Dr. Ozturk is a consultant for DePuy Synthes.
Headings
References
  • 1

    Arguello FBaggs RBDuerst REJohnstone LMcQueen KFrantz CN: Pathogenesis of vertebral metastasis and epidural spinal cord compression. Cancer 65:981061990

    • Search Google Scholar
    • Export Citation
  • 2

    Bilsky MFischer CGGokasalan ZLFehlings MGBoriani SPolly D: The Spinal Instability Neoplastic Score (SINS): an analysis of reliability and validity from the Spine Oncology Study Group. Int J Radiat Oncol Biol Phys 78:S2632010

    • Search Google Scholar
    • Export Citation
  • 3

    Chan NKAbdullah KGLubelski DSteinmetz MPBenzel ECShin JH: Stereotactic radiosurgery for metastatic spine tumors. J Neurosurg Sci 58:37442014

    • Search Google Scholar
    • Export Citation
  • 4

    Choi DBilsky MFehlings MFisher CGokaslan Z: Spine oncology—metastatic spine tumors. Neurosurgery 80 (3S):S131S1372017

  • 5

    Fisher CGDiPaola CPRyken TCBilsky MHShaffrey CIBerven SH: A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 35:E1221E12292010

    • Search Google Scholar
    • Export Citation
  • 6

    Fisher CGVersteeg ALSchouten RBoriani SVarga PPRhines LD: Reliability of the spinal instability neoplastic scale among radiologists: an assessment of instability secondary to spinal metastases. AJR Am J Roentgenol 203:8698742014

    • Search Google Scholar
    • Export Citation
  • 7

    Fourney DRGokaslan ZL: Anterior approaches for thoracolumbar metastatic spine tumors. Neurosurg Clin N Am 15:4434512004

  • 8

    Fox SSpiess MHnenny LFourney DR: Spinal Instability Neoplastic Score (SINS): reliability among spine fellows and resident physicians in orthopedic surgery and neurosurgery. Global Spine J 7:7447482017

    • Search Google Scholar
    • Export Citation
  • 9

    Gerszten PCBurton SAOzhasoglu CWelch WC: Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 32:1931992007

    • Search Google Scholar
    • Export Citation
  • 10

    Ghogawala ZMansfield FLBorges LF: Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine (Phila Pa 1976) 26:8188242001

    • Search Google Scholar
    • Export Citation
  • 11

    Gokaslan ZLYork JEWalsh GLMcCutcheon IELang FFPutnam JB Jr: Transthoracic vertebrectomy for metastatic spinal tumors. J Neurosurg 89:5996091998

    • Search Google Scholar
    • Export Citation
  • 12

    Hoskin PMisra VHopkins KHolt TBrown GArnott S: SCORAD III: randomized noninferiority phase III trial of single-dose radiotherapy (RT) compared to multifraction RT in patients (pts) with metastatic spinal canal compression (SCC). J Clin Oncol 35:LBA100042017

    • Search Google Scholar
    • Export Citation
  • 13

    Howell DDJames JLHartsell WFSuntharalingam MMachtay MSuh JH: Single-fraction radiotherapy versus multifraction radiotherapy for palliation of painful vertebral bone metastases-equivalent efficacy, less toxicity, more convenient: a subset analysis of Radiation Therapy Oncology Group trial 97-14. Cancer 119:8888962013

    • Search Google Scholar
    • Export Citation
  • 14

    Hsu WSciubba DMSasson ADKhavkin YWolinsky JPGailloud P: Intraoperative localization of thoracic spine level with preoperative percutaneous placement of intravertebral polymethylmethacrylate. J Spinal Disord Tech 21:72752008

    • Search Google Scholar
    • Export Citation
  • 15

    Klimo P JrSchmidt MH: Surgical management of spinal metastases. Oncologist 9:1881962004

  • 16

    Lam TCUno HKrishnan MLutz SGroff MCheney M: Adverse outcomes after palliative radiation therapy for uncomplicated spine metastases: role of spinal instability and single-fraction radiation therapy. Int J Radiat Oncol Biol Phys 93:3733812015

    • Search Google Scholar
    • Export Citation
  • 17

    Laufer IRubin DGLis ECox BWStubblefield MDYamada Y: The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 18:7447512013

    • Search Google Scholar
    • Export Citation
  • 18

    Lee CSJung CH: Metastatic spinal tumor. Asian Spine J 6:71872012

  • 19

    Moussazadeh NLaufer IYamada YBilsky MH: Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals. Cancer Contr 21:1681742014

    • Search Google Scholar
    • Export Citation
  • 20

    Padalkar PTow B: Predictors of survival in surgically treated patients of spinal metastasis. Indian J Orthop 45:3073132011

  • 21

    Patchell RATibbs PARegine WFPayne RSaris SKryscio RJ: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366:6436482005

    • Search Google Scholar
    • Export Citation
  • 22

    Versteeg ALvan der Velden JMVerkooijen HMvan Vulpen MOner FCFisher CG: The effect of introducing the Spinal Instability Neoplastic Score in routine clinical practice for patients with spinal metastases. Oncologist 21:951012016

    • Search Google Scholar
    • Export Citation
  • 23

    Wise JJFischgrund JSHerkowitz HNMontgomery DKurz LT: Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 24:194319511999

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 132 132 132
Full Text Views 7 7 7
PDF Downloads 11 11 11
EPUB Downloads 0 0 0
PubMed
Google Scholar