OBJECTIVE: We aim to validate the Global Spine Tumor Study Group (GSTSG) score compared to previous prognostic scoring systems in spinal metastasis.
METHODS: We conducted a retrospective study from January 2013 to December 2022. The survival prediction was compared between the GSTSG, Tomita Score, Revised Tokuhashi Score, and Skeletal Oncology Research Group (SORG) Nomogram. Single-variable factors associated with survival rate were analyzed using univariate Cox regression and multivariable Cox proportional hazard model. Receiver operating characteristic was used for external validity analysis at 3, 6, 12, and 24 months. The overall survival rate was reported using the Kaplan-Meier survival curve.
RESULTS: 248 spinal metastasis patients were included. The mean age was 59.23 ± 12.55 years. The mean duration of follow-up time was 470.29 ± 441.98 days. The external validity of GSTSG was the highest at all follow-up times (sufficiently accurate AUC > 0.7), which was about the same as SORG at 3 months (both AUC of GSTSG and SORG = 0.76) and higher than modified Tokuhashi and Tomita score at 12 months (AUC of GSTSG = 0.78, SORG = 0.71, Tomita = 0.64, and modified Tokuhashi = 0.61, respectively).
CONCLUSIONS: From our study, the Multivariate Cox regression analysis indicates that the significant factors related to survival rate are regular analgesic use of weak opioids, lung metastasis, and previous chemotherapy. Compared to other traditional spinal metastases prognostic scoring systems, GSTSG shows the highest AUC for external validity in all follow-up times up to 24 months.

BACKGROUND: One important determinant in choosing a treatment modality is spinal instability. Clear management guidelines are suggested for stable and unstable spinal metastatic lesions, but lesions in the intermediate instability category (SINS [spinal instability neoplastic score] score of 7-12) remain a clinical dilemma. This study aims to analyze the risk factors necessitating surgical intervention after radiotherapy (RT) in patients with those lesions.
METHODS: A multicenter cohort of 469 patients with spinal metastases of intermediate instability who received radiotherapy (RT) as the initial treatment between 2019 and 2021 were retrospectively enrolled. All patients were neurologically intact at the time of RT. According to the performance of surgical intervention after RT, various clinical and radiographic risk factors for surgical intervention were compared between surgery and non-surgery groups using uni- and multivariate analyses. A recursive partitioning analysis (RPA) was performed using significant determinants identified in multivariate analysis.
RESULTS: The mean age at the time of RT was 59.9 years and there were 198 females. The lung was the most common primary site. During the mean follow-up duration of 18.2 months, surgical treatment was required in 79 (17.9%) of patients. The most common surgical method was decompressive laminectomy with stabilization (62.0%), followed by vertebrectomy with stabilization (22.8%) and stabilization only (15.2%). The mean SINS for the total cohort was 9.0. Multivariate regression analyses revealed that the primary tumor site of the lung, liver, and kidney, higher Bilsky grades of ESCC, lytic bone lesions, and higher EQD210 were significant risk factors for surgical intervention after RT. Among them, Bilsky grade, primary tumor type of the lung, liver, and kidney, and EQD210 were the most important determinants for expecting the probability of surgical intervention on RPA.
CONCLUSIONS: Surgical intervention was performed in 17.9% of patients with intermediate instability after RT as the initial treatment. The primary tumor site of the lung, liver, and kidney, higher Bilsky grade of ESCC, and EQD210 were the most important determinants for expecting the probability of surgical intervention. Therefore, the optimal treatment strategy needs to be devised by carefully evaluating the risk of surgical intervention.

BACKGROUND: The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes.
METHODS: In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge.
RESULTS: A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01).
CONCLUSIONS: Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient\'s preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk-benefit analysis and optimizing perioperative care.

UNASSIGNED: Spinal metastases are a significant complication of advanced cancer. In this study, we assess temporal trends in the incidence and timing of spinal metastases and examine underlying patient demographics and primary cancer associations.
UNASSIGNED: In this population-based retrospective cohort study, health data from 2007 to 2019 in Ontario, Canada were analyzed (n = 37, 375 patients identified with spine metastases). Primary outcomes were annual incidence of spinal metastasis, and time to metastasis after primary diagnosis.
UNASSIGNED: The age-standardized incidence of spinal metastases increased from 229 to 302 cases per million over the 13-year study period. The average annual percent change (AAPC) in incidence was 2.2% (95% CI: 1.4% to 3.0%) with patients aged ≥85 years demonstrating the largest increase (AAPC 5.2%; 95% CI: 2.3% to 8.3%). Lung cancer had the greatest annual incidence, while prostate cancer had the greatest increase in annual incidence (AAPC 6.5; 95% CI: 4.1% to 9.0%). Lung cancer patients were found to have the highest risk of spine metastasis with 10.3% (95% CI: 10.1% to 10.5%) of patients being diagnosed at 10 years. Gastrointestinal cancer patients were found to have the lowest risk of spine metastasis with 1.0% (95% CI: 0.9% to 1.0%) of patients being diagnosed at 10 years.
UNASSIGNED: The incidence of spinal metastases has increased in recent years, particularly among older patients. The incidence and timing vary substantially among different primary cancer types. These findings contribute to the understanding of disease trends and emphasize a growing population of patients who require subspecialty care.

Background: Malnutrition is a common condition that may exacerbate many medical and surgical pathologies. However, few have studied the impact of malnutrition on surgical outcomes for patients undergoing surgery for metastatic disease of the spine. This study aims to evaluate the impact of malnutrition on perioperative complications and healthcare resource utilization following surgical treatment of spinal metastases. Methods: We conducted a retrospective cohort study using the 2011-2019 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients with spinal metastases who underwent laminectomy, corpectomy, or posterior fusion for extradural spinal metastases were identified using the CPT, ICD-9-CM, and ICD-10-CM codes. The study population was divided into two cohorts: Nourished (preoperative serum albumin values ≥ 3.5 g/dL) and Malnourished (preoperative serum albumin values < 3.5 g/dL). We assessed patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), hospital LOS, discharge disposition, readmission, and reoperation. Multivariate logistic regression analyses were performed to identify the factors associated with a prolonged length of stay (LOS), AEs, non-routine discharge (NRD), and unplanned readmission. Results: Of the 1613 patients identified, 26.0% were Malnourished. Compared to Nourished patients, Malnourished patients were significantly more likely to be African American and have a lower BMI, but the age and sex were similar between the cohorts. The baseline comorbidity burden was significantly higher in the Malnourished cohort compared to the Nourished cohort. Compared to Nourished patients, Malnourished patients experienced significantly higher rates of one or more AEs (Nourished: 19.8% vs. Malnourished: 27.6%, p = 0.004) and serious AEs (Nourished: 15.2% vs. Malnourished: 22.6%, p < 0.001). Upon multivariate regression analysis, malnutrition was found to be an independent and associated with an extended LOS [aRR: 3.49, CI (1.97, 5.02), p < 0.001], NRD [saturated aOR: 1.76, CI (1.34, 2.32), p < 0.001], and unplanned readmission [saturated aOR: 1.42, CI (1.04, 1.95), p = 0.028]. Conclusions: Our study suggests that malnutrition increases the risk of postoperative complication, prolonged hospitalizations, non-routine discharges, and unplanned hospital readmissions. Further studies are necessary to identify the protocols that pre- and postoperatively optimize malnourished patients undergoing spinal surgery for metastatic spinal disease.

OBJECTIVE: Despite advancements in spinal metastasis surgery techniques and the rapid development of multidisciplinary treatment models, we aimed to explore the clinical efficacy of spinal metastasis surgery performed by a combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system, compared with the Revised Tokuhashi scoring system.
METHODS: Clinical data from 102 patients with spinal metastases who underwent surgery at three affiliated hospitals of Zunyi Medical University from December 2017 to June 2022 were analysed. The patients were randomly assigned to two groups: 52 patients in the treatment group involving the combined NOMS decision system-utilizing multidisciplinary team and Revised Tokuhashi scoring system (i.e., the combined group), and 50 patients in the treatment group involving the Revised Tokuhashi scoring system only (i.e., the revised TSS-only group). Moreover, there were no statistically significant differences in preoperative general data or indicators between the two groups. Intraoperative and postoperative complications, average hospital stay, mortality rate, and follow-up observation indicators, including the visual analogue scale (VAS) score for pain, Eastern Cooperative Oncology Group (ECOG) performance status, Karnofsky Performance Status (KPS) score, negative psychological assessment score (using the Self-Rating Anxiety Scale, [SAS]), and neurological function recovery score (Frankel functional classification) were compared between the two groups.
RESULTS: All 102 patients successfully completed surgery and were discharged. The follow-up period ranged from 12 to 24 months, with an average of (13.2 ± 2.4) months. The patients in the combined group experienced fewer complications such as surgical wound infections 3 patients(5.77%), intraoperative massive haemorrhage 2 patients(3.85%), cerebrospinal fluid leakage 2 patients(3.85%), deep vein thrombosis 4 patients(7.69%),and neurological damage 1 patient(1.92%), than patients in the revised TSS-only group (wound infections,11 patients(22%); intraoperative massive haemorrhage, 8 patients(16%);cerebrospinal fluid leakage,5 patients(10%);deep vein thrombosis,13 patients (26%); neurological damage,2 patients (4%). Significant differences were found between the two groups in terms of surgical wound infections, intraoperative massive haemorrhage, and deep vein thrombosis (P < 0.05). The average postoperative hospital stay in the combined group (7.94 ± 0.28 days) was significantly shorter than that in the revised TSS-only group (10.33 ± 0.30 days) (P < 0.05). Long-term follow-up (1 month, 3 months, 6 months, and 1 year postoperatively) revealed better clinical outcomes in the combined group than in the revised TSS-only group in terms of VAS scores, overall KPS%, neurological function status Frankel classification, ECOG performance status, and SAS scores.(P < 0.05).
CONCLUSIONS: A multidisciplinary team using the NOMS combined with the Revised Tokuhashi scoring system for spinal metastasis surgery showed better clinical efficacy than the sole use of the Revised Tokuhashi scoring system. This personalized, precise, and rational treatment significantly improves patient quality of life, shortens hospital stay, reduces intraoperative and postoperative complications, and lowers mortality rates.

Background and Objectives: Bone metastasis cancer boards (BMCBs) focusing on the management of bone metastases have been gathering much attention. However, the association of BMCBs with spinal surgery in patients with spinal metastases remains unclear. In this retrospective single-center observational study, we aimed to clarify the effect of a BMCB on spinal metastasis treatment. Materials and Methods: We reviewed consecutive cases of posterior decompression and/or instrumentation surgery for metastatic spinal tumors from 2008 to 2019. The BMCB involved a team of specialists in orthopedics, rehabilitation medicine, radiation oncology, radiology, palliative supportive care, oncology, and hematology. We compared demographics, eastern cooperative oncology group performance status (ECOGPS), Barthel index (BI), number of overall versus emergency surgeries, and primary tumors between patients before (2008-2012) and after (2013-2019) BMCB establishment. Results: A total of 226 patients including 33 patients before BMCB started were enrolled; lung cancer was the most common primary tumor. After BMCB establishment, the mean patient age was 5 years older (p = 0.028), the mean operating time was 34 min shorter (p = 0.025), the mean hospital stay was 34.5 days shorter (p < 0.001), and the mean BI before surgery was 12 points higher (p = 0.049) than before. Moreover, the mean number of surgeries per year increased more than fourfold to 27.6 per year (p < 0.01) and emergency surgery rates decreased from 48.5% to 29.0% (p = 0.041). Patients with an unknown primary tumor before surgery decreased from 24.2% to 9.3% (p = 0.033). Postoperative deterioration rates from 1 to 6 months after surgery of ECOGPS and BI after BMCB started were lower than before (p = 0.045 and p = 0.027, respectively). Conclusion: The BMCB decreased the emergency surgery and unknown primary tumor rate despite an increase in the overall number of spinal surgeries. The BMCB also contributed to shorter operation times, shorter hospital stays, and lower postoperative deterioration rates of ECOGPS and BI.

OBJECTIVE: Hypervascular spinal metastatic malignancies can cause severe pain and intraoperative bleeding and selection of appropriate treatment can be challenging. This study aimed to observe the short-term efficacy and safety of Iodine-125 brachytherapy (125I BT) combined with preoperative transcatheter arterial chemoembolization (TACE) for hypervascular spinal metastasis.
METHODS: This study included a total of 33 patients (39 lesions) with hypervascular spinal metastasis. All of them carried out a regimen of TACE followed by 125I BT under CT guidance. A brachytherapy planning system has been utilized for the purpose of designing treatment plans and optimizing dose distribution. Pain relief was evaluated using a numeric rating scale (NRS) and intraoperative bleeding was recorded. Follow-up was conducted for 6 months to observe the local control rate and clinical complications.
RESULTS: All patients tolerated combined treatment well and intraoperative blood loss of every patient was not more than 10 ml. The 2- and 6- month local disease control rates were 92.3% and 83.8%. The NRS scores for thirty-three tumor patients before surgery and after one week, two, and six months of surgery were recorded as 7.33 ± 1.80, 7.39 ± 1.89, 3.15 ± 2.35, and 4.16 ± 2.15, respectively. The NRS score 2 months after treatment was found considerably lower in comparison to the NRS score before operation (p < 0.05).
CONCLUSIONS: According to our findings, 125I BT as well as preoperative TACE leads to perioperative hemostasis, pain alleviation, and reduced tumor burden, indicating that this combined treatment could be effective and promising for hypervascular spinal metastases.

This study aimed to investigate the clinical outcomes of total en bloc spondylectomy (TES) for spinal metastases previously treated with radiotherapy (RT). This study enrolled 142 patients who were divided into two groups: those with and those without an RT history. Forty-two patients were selected from each group through propensity score matching, and postoperative complications, local recurrence, and overall survival rates were compared. The incidence of postoperative complications was significantly higher in the group with an RT history than in the group without an RT history (57.1% vs. 35.7%, respectively). The group with an RT history had a higher local recurrence rate than the group without an RT history (1-year rate: 17.5% vs. 0%; 2-year rate: 20.8% vs. 2.9%; 5-year rate: 24.4% vs. 6.9%). The overall postoperative survival tended to be lower in the group with an RT history; however, there was no significant difference between the two groups (2-year survival: 64.3% vs. 66.7%; 5-year survival: 47.3% vs. 57.1%). When planning a TES for irradiated spinal metastases, the risk of postoperative complications and local recurrence should be fully considered.

Spine surgeons should weigh the risks of anticoagulants against their benefits in preventing deep venous thrombosis (DVT), as they may increase the risk of bleeding. Spinal metastasis patients undergoing decompression with fixation are at a high risk for DVT, which may occur preoperatively. Therefore, anticoagulants should be administered preoperatively. This study aimed to evaluate the safety of the administration of anticoagulants in treating spinal metastasis patients with preoperative DVT. Therefore, we prospectively investigated the prevalence of DVT in these patients. Patients who were diagnosed with preoperative DVT were included in an anticoagulant group. Subcutaneous low-molecular-weight heparin (LMWH) was administered. Patients without DVT were included in a non-anticoagulant group. Data on patient information, clinical parameters, blood test results, and bleeding complications were also collected. Moreover, the safety of anticoagulants was analyzed. The prevalence of preoperative DVT was 8.0%. None of the patients developed pulmonary thromboembolism. Furthermore, no significant differences in blood loss, drainage volume, hemoglobin levels, number of transfusions, or preoperative trans-catheter arterial embolization were observed between the two groups. None of the patients developed major bleeding. However, two patients experienced wound hematoma and one experienced incisional bleeding in the non-anticoagulant group. Therefore, LMWH is safe for spinal metastasis patients. Future randomized controlled trials should be conducted to evaluate the validity of perioperative prophylactic anticoagulation therapy in these patients.