Spine Surgery For Metastases Research Articles

Impact of Targeted Systemic Therapy and Radiotherapy on Patients Undergoing Spine Surgery for Metastatic Renal Cell Carcinoma.

In patients undergoing spine surgery for renal cell carcinoma (RCC), we sought to: (1) describe patterns of postoperative targeted systemic therapy and radiotherapy (RT), (2) compare perioperative outcomes among those treated with targeted systemic therapy to those without, and (3) evaluate the impact of targeted systemic therapy and/or RT on overall survival (OS) and local recurrence (LR). A single-institution, retrospective cohort study of patients undergoing spine surgery for metastatic RCC from 2010 to 2021 was undertaken. Treatment groups were RT alone, targeted systemic therapy alone, dual therapy consisting of RT and targeted systemic therapy, and neither therapy. Multivariable Cox regression controlled for age, race, sex, insurance, and preoperative targeted systemic therapy. Forty-nine patients underwent spine surgery for RCC. Postoperatively, 4 patients (8%) received RT alone, 19 (38.8%) targeted systemic therapy alone, 12 (24.5%) dual therapy, and 13 (28.6%) neither. All groups were similar in demographics, preoperative Karnofsky Performance Score (P = 0.372), tumor size (P = 0.413), readmissions (P = 0.884), complications (P = 0.272), Karnofsky Performance Score (P = 0.466), and Modified McCormick Scale (P = 0.980) at last follow-up. Higher 1-year survival was found in dual therapy (83.3%) compared with other therapies. OS was significantly longer in patients with dual therapy compared with other therapies (log-rank; P = 0.010). Multivariate Cox regression (HR = 0.08, 95% CI = 0.02-0.31, P < 0.001) showed longer OS in dual therapy compared with other therapies. Seven patients (14.3%) experienced LR, and a similar time to LR was found between groups (log-rank; P = 0.190). In patients undergoing metastatic spine surgery for RCC, postoperative dual therapy demonstrated significantly higher 1-year survival and OS compared with other therapies. Multidisciplinary management of metastatic RCC is necessary to ensure timely implementation of targeted systemic therapy and RT to improve outcomes.

Obstacles to receiving postoperative radiation therapy following separation surgery for metastatic spine disease.

Obtaining timely postoperative radiotherapy (RT) following separation surgery is critical to avoid local recurrence of disease yet can be a challenge due to scheduling conflicts, insurance denials, and travel arrangements. In patients undergoing metastatic spine surgery for spinal cord compression, the authors sought to: 1) report the rate of postoperative RT, 2) describe reasons for patients not receiving postoperative RT, and 3) investigate factors that may predict whether a patient receives postoperative RT. A single-center retrospective case series was undertaken of all patients who underwent metastatic spine surgery for extradural disease between January 2010 and January 2021. Inclusion criteria were patients with intermediate or radioresistant tumors with evidence of spinal cord compression who underwent surgery. The primary outcome was the occurrence of RT within 3 months following surgery. Multivariable logistic regression analysis was performed controlling for age, BMI, race, total number of decompressed levels, tumor size, other organ metastasis, and preoperative RT or chemotherapy to predict patients receiving postoperative RT. Of 239 patients undergoing spine surgery for metastatic disease, 113 (47.3%) received postoperative RT while 126 (52.7%) did not. In the postoperative RT group, 24 (21.2%) received stereotactic body radiation therapy while 89 (78.8%) received conventional external-beam radiation therapy. The most common reasons for patients not receiving postoperative RT included death or transfer to hospice (31.0%), RT not being recommended by radiation oncology (30.2%), and loss to follow-up (23.8%). On critical review with the radiation oncology department, the authors estimated that 101 of 126 (80.2%) patients who did not receive postoperative RT were potential candidates for postoperative RT. Patients who received postoperative RT had more documented inpatient (48.7% vs 32.5%, p < 0.001) and outpatient (100.0% vs 65.1%, p < 0.001) radiation oncology consultations than those who did not. Additionally, patients who received postoperative RT had a higher rate of postoperative chemotherapy (53.1% vs 25.4%, p < 0.001), while patients who did not receive postoperative RT had a higher rate of preoperative RT (7.1% vs 31.0%, p < 0.001). Multivariable analysis confirmed that patients who received preoperative RT had lower odds of undergoing postoperative RT (OR 0.14, 95% CI 0.06-0.34; p < 0.001), and patients who underwent postoperative chemotherapy had higher odds of undergoing postoperative RT (OR 3.83, 95% CI 2.05-7.17; p < 0.001). In the current study reflecting real-world care of patients with metastatic spine disease after undergoing separation surgery, 47% of patients did not receive postoperative RT, and 80% of those patients were potential candidates for postoperative RT. Radiation oncology consultation and postoperative chemotherapy were significantly associated with receiving postoperative RT, whereas preoperative RT was significantly associated with not receiving postoperative RT. The lack of timely postoperative RT highlights a potential gap in metastatic spine tumor care and underscores the necessity for prompt radiation oncology consultation and effective planning.

Does Timing of Radiation Therapy Impact Wound Healing in Patients Undergoing Metastatic Spine Surgery?

The impact of radiation on wound healing after metastatic spine surgery remains an active area of research. In patients undergoing metastatic spine surgery, we sought to (1) assess the relationship between preoperative and/or postoperative radiation on wound complications, and (2) evaluate the relationship between the timing of postoperative radiation and wound complications. A single-center, retrospective, cohort study of patients undergoing metastatic spine surgery was conducted from 2010 to 2021. The primary exposure variable was the use/timing of radiation. Radiation included both external beam radiotherapy (EBRT) and stereotactic body radiotherapy (SBRT). Patients were trichotomized into the following groups: (1) preoperative radiation only, (2) postoperative radiation only, and (3) no radiation. The primary outcome variable was wound complications, which was defined as dehiscence requiring reoperation, infection requiring antibiotics, or infection requiring surgical debridement. Multivariable logistic/linear regression controlled for age, tumor size, primary organ of origin, and the presence of other organ metastases. A total of 207 patients underwent surgery for extradural spinal metastasis. Participants were divided into three groups: preoperative RT only (N = 29), postoperative RT only (N = 91), and no RT (N = 178). Patients who received postoperative RT only and no RT were significantly older than patients who received preoperative RT only (p = 0.009) and were less likely to be white (p < 0.001). No other significant differences were found in basic demographics, tumor characteristics, or intraoperative variables. Wound-related complications occurred in two (6.9%) patients with preoperative RT only, four patients (4.4%) in postoperative RT only, and 11 (6.2%) patients with no RT, with no significant difference among the three groups (p = 0.802). No significant difference was found in wound-related complications, reoperation, and time to wound complications between patients with preoperative RT only and no RT, and between postoperative RT only and no RT (p > 0.05). Among the postoperative-RT-only group, no difference in wound complications was seen between those receiving SBRT (5.6%) and EBRT (4.1%) (p > 0.999). However, patients who received preoperative RT only had a longer time to wound complications in comparison to those who received postoperative RT only (43.5 ± 6.3 vs. 19.7 ± 3.8, p = 0.004). Regarding timing of postoperative RT, the mean (SD) time to RT was 28.7 ± 10.0 days, with a median of 28.7 (21-38) days. No significant difference was found in time to postoperative RT between patients with and without wound complications (32.9 ± 12.3 vs. 29.0 ± 9.7 days, p = 0.391). In patients undergoing metastatic spine surgery, a history of previous RT or postoperative RT did not significantly affect wound complications. However, those with previous RT prior to surgery had a longer time to wound complications than patients undergoing postoperative RT only. Moreover, timing of RT had no impact on wound complications, indicating that earlier radiation may be safely employed to optimize tumor control without fear of compromising wound healing.

Does Elective Admission vs. Emergency Department Presentation Affect Surgical Outcomes in Metastatic Spine Surgery?

Approximately 20% of patients with metastatic spine disease develop symptomatic spinal cord compression, and these patients can present urgently to the emergency department (ED) or, in a more organized fashion, to a clinic. In a cohort of patients undergoing metastatic spine surgery, we sought to (1) determine the rate of ED presentation, (2) identify preoperative and perioperative risk factors associated with ED presentation, and (3) evaluate whether ED vs. clinic presentation impacts long-term outcomes. A single-institution, multi-surgeon, retrospective cohort study was undertaken of patients undergoing metastatic spinal tumor surgery between 02/2010 and 01/2021. The primary exposure variable was presentation setting, dichotomized to the ED vs. clinic. The primary outcomes were postoperative functional status, measured with the Karnofsky Performance Scale (KPS) and McCormick Scale (MMS), local recurrence (LR), and overall survival (OS). Secondary outcomes included complications and readmissions. A total of 311 patients underwent metastatic spine surgery (51.7% ED vs. 48.3% clinic). Those presenting to the ED had higher rates of smoking (21.7% vs. 16.0%, p = 0.02), were more likely to have 2+ comorbidities (47.2% vs. 32.7%, p = 0.011), and were more likely to have public insurance (43.5% vs. 32.0%, p = 0.043). Preoperative KPS was lower in ED patients (p < 0.001), while the Bilsky score was higher (p = 0.049). ED patients had higher rates of oligometastatic disease (p = 0.049), higher total decompressed levels (p = 0.041), and higher rates of costotransversectomy (p = 0.031) compared to clinic patients. Length of stay was significantly longer for ED patients (7.7 ± 6.1 vs. 6.1 ± 5.8 days, p = 0.020), and they were less likely to be discharged home (52.2% vs. 69.3%, p = 0.025). ED presentation was significantly associated with shorter overall survival (HR =1.53 95% CI = 1.13-2.08, p = 0.006). Of patients undergoing metastatic spine disease, approximately half presented through the ED vs. clinic. ED patients had higher rates of smoking, public insurance, and higher Bilsky score. ED patients also underwent more extensive surgery, had longer LOS, were less likely discharged home, and most importantly, had a shorter overall survival. These results suggest that initial presentation for patients undergoing surgery for metastatic spine disease significantly impacts outcomes, and signs/symptoms of metastatic spine disease should be recognized as soon as possible to prevent ED presentation.

Earlier Radiation Is Associated with Improved 1-Year Survival After Metastatic Spine Tumor Surgery

ObjectivesIn patients undergoing metastatic spine surgery, we sought to: 1) report time to postoperative radiation therapy (RT), 2) describe the predictive factors of time to postoperative RT, and 3) determine if earlier postoperative RT is associated with improved local recurrence (LR) and overall survival (OS). MethodsA single-center, retrospective cohort study was undertaken of all patients undergoing spine surgery for extradural metastatic disease and receiving RT within 3-months postoperatively between 02/2010-01/2021. Time to postoperative RT was dichotomized at <1month vs. 1-3months. The primary outcomes were LR, OS, and 1-year survival. Secondary outcomes were wound complication, Karnofsky Performance Scale (KPS), and Modified McCormick Scale (MMS). Regression analyses controlled for age, BMI, tumor size, preoperative RT, preoperative/postoperative chemotherapy, and type of RT. ResultsOf 76 patients undergoing spinal metastasis surgery and receiving postoperative RT within 3-months, 34(44.7%) received RT within 1month and 42(55.2%) within 1-3months. Patients with larger tumor size (β=-3.58,95%CI=-6.59,-0.57,p=0.021) or new neurological deficits (β=-16.21,95%CI=-32.21,-0.210,p=0.047) had a shorter time to RT. No significant association was found between time to RT and LR or OS on multivariable logistic/Cox regression. However, patients who received RT between 1-3month had a lower odd of 1-year survival compared to those receiving RT within 1month (OR=0.18,95%CI=0.04-0.74,p=0.022). Receiving RT within 1month vs. 1-3month was not associated with wound complications (7.1% vs. 2.9%,p=0.556)(OR=4.40,95%CI=0.40-118.0,p=0.266) or KPS/MMS. ConclusionsSpine surgeons, oncologists, and radiation oncologists should make every effort to start RT within 1 month to improve 1-year survival after metastatic spine tumor surgery.

Factors associated with complications and reoperations in metastatic spine surgery–JASA multicenter study–

Factors associated with complications and reoperations in metastatic spine surgery–JASA multicenter study–

Is it necessary to revise the metastatic spine surgery scores for lung cancer?

Is it necessary to revise the metastatic spine surgery scores for lung cancer?

73. What is the ideal time to start radiation after metastatic spine surgery?

73. What is the ideal time to start radiation after metastatic spine surgery?

Does Low-Grade Versus High-Grade Bilsky Score Influence Local Recurrence and Overall Survival in Metastatic Spine Tumor Surgery?

Spinal cord compression caused by spinal tumors is measured using the epidural spinal cord compression scale, also known as the Bilsky score. Whether Bilsky score predicts short-/long-term outcomes remains unknown. The objectives were to determine the correlation of Bilsky score 0-1 vs 2-3 with regards to (1) preoperative presentation, (2) perioperative variables, and (3) long-term outcomes. A single-center, retrospective evaluation of a cohort of patients undergoing metastatic spine surgery was performed between 01/2010 and 01/2021. Multivariable logistic/linear/Cox regression were performed controlling for age, body mass index, race, total decompressed levels, tumor size, other organ metastases, and postoperative radiotherapy/chemotherapy. Of 343 patients with extradural spinal metastasis, 92 (26.8%) were Bilsky 0-1 and 251 (73.2%) were Bilsky 2-3. Preoperatively, patients with Bilsky 2-3 lesions were older ( P = .008), presented more with sensory deficits ( P = .029), and had worse preoperative Karnofsky Performance Scale (KPS) ( P = .002). Perioperatively, Bilsky 2-3 patients had more decompressed levels ( P = .005) and transpedicular decompression ( P < .001), with similar operative time ( P = .071) and blood loss ( P = .502). Although not statistically significant, patients with Bilsky 2-3 had more intraoperative neuromonitoring changes ( P = .412). Although rates of complications ( P = .442) and neurological deficit ( P = .852) were similar between groups, patients with Bilsky 2-3 lesions had a longer length of stay ( P = .007) and were discharged home less frequently ( P < .001). No difference was found in 90-day readmissions ( P = .607) and reoperation ( P = .510) Long-term: LR ( P =.100) and time to LR (log-rank; P =0.532) were not significantly different between Bilsky 0-1 and Bilsky 2-3 lesions. However, patients with Bilsky 2-3 lesions had worse postoperative KPS ( P < .001), worse modified McCormick scale score ( P = .003), shorter overall survival (OS) (log-rank; P < .001), and worse survival at 1 year ( P = .012). Bilsky 2-3 lesions were associated with shorter OS on multivariable Cox regression (hazard ratio = 1.78, 95% CI = 1.27-2.49, P < .001), with no significant impact on time to LR (hazard ratio = 0.73, 95% CI = 0.37-1.44, P = .359). Bilsky 2-3 lesions were associated with longer length of stay, more nonhome discharge, worse postoperative KPS/modified McCormick scale score, shorter OS, and reduced survival at 1 year. Higher-grade Bilsky score lesions appear to be at a higher risk for worse outcomes. Efforts should be made to identify metastatic spine patients before they reach the point of severe spinal cord compression..

Hypoalbuminemia as a Predictor of Mortality, Disability, and Readmission in Patients Undergoing Spine Surgery: A Retrospective Analysis.

This was a retrospective cohort study. The objective of this study was to clarify the association between preoperative albumin status and mortality and morbidity in lumbar spine surgery. Hypoalbuminemia is a known marker of inflammation and is associated with frailty. Hypoalbuminemia is an identified risk factor for mortality following spine surgery for metastases, yet has not been well studied among spine surgical cohorts outside of metastatic cancer. We identified patients with preoperative serum albumin laboratory values who underwent lumbar spine surgery at a US public university health system between 2014 and 2021. Demographic, comorbidity, and mortality data were collected along with preoperative and postoperative Oswestry Disability Index (ODI) scores. Any cause readmission within 1 year of surgery was recorded. Hypoalbuminemia was defined as <3.5g/dL in serum. We examined the Kaplan-Meier survival plots based on serum albumin. Multivariable regression models were used to identify the association between preoperative hypoalbuminemia with mortality, readmission, and ODI, while controlling for age, sex, race, ethnicity, procedure, and Charlson Comorbidity Index. Of 2573 patients, 79 were identified as hypoalbuminemic. Hypoalbuminemic patients had a significantly greater adjusted risk of mortality through 1 year (odds ratio=10.2; 95% CI: 3.1-33.5; P <0.001), and 7 years (hazard ratio=4.18; 95% CI: 2.29-7.65; P <0.001). Hypoalbuminemic patients had ODI scores 13.5 points higher (95% CI: 5.7-21.4; P <0.001) at baseline. Adjusted readmission rates were not different between groups through 1 year (odds ratio=1.15; 95% CI: 0.5-2.62; P =0.75) or through full surveillance (hazard ratio=0.82; 95% CI: 0.44-1.54; P =0.54). Preoperative hypoalbuminemia was strongly associated with postoperative mortality. Hypoalbuminemic patients did not have demonstrably worse outcomes in their functional disability beyond 6 months. Within the first 6 months following surgery, the hypoalbuminemic group improved at a similar rate to the normoalbuminemic group despite having a greater preoperative disability. However, causal inference is limited in this retrospective study.

Unplanned Readmission Is Associated With Decreased Overall Survival and Performance After Metastatic Spine Surgery.

Retrospective case-control study. In a cohort of patients undergoing metastatic spine surgery, we sought to: (1) identify risk factors associated with unplanned readmission, and (2) determine the impact of an unplanned readmission on long-term outcomes. Factors affecting readmission after metastatic spine surgery remain relatively unexplored. A single-center, retrospective, case-control study was undertaken of patients undergoing spine surgery for extradural metastatic disease between 02/2010 and 01/2021. The primary outcome was 3-month unplanned readmission. Preoperative, perioperative, and tumor-specific variables were collected. Multivariable Cox regression was performed, controlling for tumor size, other organ metastasis, and preoperative/postoperative radiotherapy/chemotherapy. A total of 357 patients underwent surgery for spinal metastases with a mean follow-up of 538.7±648.6 days. Unplanned readmission within 3 months of surgery occurred in 64/357 (21.9%) patients, 37 (57.8%) were medical, 27 (42.2%) surgical, and 21 (77.7%) were related to their spine surgery. No significant differences were found regarding demographics and preoperative variables, except for insurance, where most readmitted patients had private insurance compared with nonreadmitted patients ( P =0.021). No significant difference was found in preoperative radiotherapy/chemotherapy. Regarding perioperative exposure variables, readmitted patients had a higher rate of postoperative complications (68.8% vs. 24.2%, P <0.001) and worse postoperative Karnofsky Performance Score ( P =0.021) and Modified McCormick Scale ( P =0.015) at the time of first follow-up. On multivariate logistic regression, postoperative complications were associated with increased readmissions (odds ratio=1.38, 95% CI=1.25-1.52, P <0.001). Regarding the impact of unplanned readmission on long-term tumor control, unplanned readmission was associated with shorter time to local recurrence (log-rank; P =0.029) and reduced overall survival (OS) (log-rank; P <0.001). On multivariate Cox regression, other organ metastasis [hazard ratio (HR)=1.48, 95% CI=1.13-1.93, P =0.004] and 3-month readmission (HR=1.75, 95% CI=1.28-2.39, P <0.001) were associated with worsened OS, with no impact on LR. Postoperative chemotherapy was significantly associated with longer OS (HR=0.59, 95% CI=0.45-0.77, P <0.001). Postoperative complications were associated with unplanned readmission following metastatic spine surgery. Furthermore, 3-month unplanned readmission was associated with a shorter time to local recurrence and decreased OS. These results help surgeons understand the drivers of readmissions and the impact of readmissions on patient outcomes. 3.

Assessment of Frailty Indices and Charlson Comorbidity Index for Predicting Adverse Outcomes in Patients Undergoing Surgery for Spine Metastases: A National Database Analysis

The aim of this study was to assess the predictive ability of Metastatic Spinal Tumor Frailty Index (MSTFI) and the Modified 5-Item Frailty Index (mFI-5) on adverse outcomes, compared with the known Charlson Comorbidity Index (CCI). A retrospective cohort study was performed using National Surgical Quality Improvement Program database from 2011 to 2019. All adult patients undergoing various procedures for extradural spinal metastases were identified. Patients were stratified into frail and nonfrail cohorts based on CCI, mFI-5, and MSTFI scores. A multivariate logistic regression analysis was used to identify independent predictors of prolonged length of stay, nonroutine discharge, adverse events, and unplanned readmission. Of the 1613 patients included in this study, 21.4% had a CCI >0, 56.6% had an mFI-5 >0, and 76.7% of patients had an MSTFI >0. On multivariate analysis, all 3 indices were found to be predictive of nonroutine discharge (CCI: adjusted odds ratio [aOR], 1.41 vs. mFI-5: aOR, 1.37 vs. MSTFI: aOR, 1.5) and adverse events (CCI: aOR, 1.53 vs. mFI-5: aOR, 1.23 vs. MSTFI: aOR, 1.43). High CCI (adjusted relative risk, 1.67) and MSTFI (adjusted relative risk, 1.14), but not mFI-5, were also associated with a prolonged length of stay, whereas MSTFI was found to be the only significant predictor of unplanned readmission (aOR, 1.22). Our study suggests that MSTFI frailty index may be more sensitive than both CCI and mFI-5 in identifying adverse outcomes after spine surgery for metastases.

Delayed postoperative radiotherapy increases the incidence of radiographic local tumor progression before radiotherapy and leads to poor prognosis in spinal metastases

BackgroundMost previous studies focused on the minimum interval between surgery and radiotherapy in spinal metastases, leaving the maximum interval under-investigated. However, in real world, limited radiotherapist and equipment cannot meet the needs of a large patient population to obtain timely radiotherapy after the index spine surgery in developing countries. This study aimed to estimate the clinical risks of delayed radiotherapy after surgery in patients with spinal metastases in developing country.MethodsData from 89 patients who underwent surgery and postoperative radiotherapy at a single site in a developing country were retrospectively reviewed. Patients were divided into the progression before radiotherapy (PBR) and no progression before radiotherapy (NPBR) groups. Kaplan–Meier analysis and log-rank tests were used to compare the local control (LC) and overall survival (OS) between groups.ResultsWithin 1 month after surgery, only 20.2% of patients underwent radiotherapy. Risk of local progression before radiotherapy at 1, 3, and 6 months was 1.2%, 24.1%, and 45.1%, respectively. The LC rate at 1 year was lower in the PBR group than in the NPBR group (53.3% vs. 76.3%, P = 0.040). The OS rate at 1 year was 61.9% and 79.6% in the PBR and NPBR groups, respectively (P = 0.001). The Karnofsky performance status significantly improved only in the NPBR group (52.5 ± 17.6 vs. 66.8 ± 26.3, P < 0.001). The sphincter dysfunction significantly improved in the NPBR group (0.3 ± 0.5 vs. 0.1 ± 0.3, P = 0.007) but it tended to be deteriorated in the PBR group (0.1 ± 0.4 vs. 0.3 ± 0.5, P = 0.500).ConclusionsIn real world, about 80% of patients had delayed radiotherapy 1 month after spine surgery for metastases in our developing country. Patients had a higher risk for radiographic local progression before radiotherapy and poorer LC, OS, and quality of life as time to radiotherapy increased.

Complications and Mortality Rates Following Surgical Management of Extradural Spine Tumors in New York State.

Database analysis. To evaluate complications and mortality in patients undergoing surgical management of extradural spinal tumors in New York State. Metastatic spine surgery has a high rate of complications but most studies are limited to single institutions. The Statewide Planning and Research Cooperative System was used to identify patients with extradural spinal tumors undergoing surgery in New York State from 2006 to 2015. Bivariate and multivariate logistic regression analyses were used to estimate outcomes. Four thousand seven hundred sixty-seven patients were identified, the majority of patients were male and white a median age of 61. The complication rate was 17.6% and the mortality rate within 30 days of discharge was 12.2%. Multivariate analysis showed the odds of complications were higher in males compared with females (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.05-1.52, P = 0.01), and patients on Medicaid compared with patients on private insurance (OR: 1.42; 95% CI: 1.03-1.96, P = 0.03). Analysis of hospital characteristics showed lower volume hospitals (OR 1.48; 95% CI: 1.03-2.13, P value = 0.03), and teaching hospitals (OR: 1.47; 95% CI: 1.03-2.09, P = 0.04), have higher odds of complications compared with high-volume hospitals and nonteaching hospitals. Multivariate analysis showed higher odds of mortality within 30 days of discharge in patients of older age (OR: 1.02; 95% CI: 1.01-1.03, P value = 0.001), low-volume hospitals compared with high-volume hospitals (OR: 1.36; 95% CI: 1.09-1.79, P value = 0.02), hospitals with low bed size compared with high bed size (OR: 1.43; 95% CI: 1.12-1.83, P value = 0.01), and urban hospitals compared with rural hospitals (OR: 3.04; 95% CI: 2.03-4.56, P value = 0.001). Low-volume hospitals are associated with complications and mortality in patients with metastatic spine disease. 3.

Changing the Adverse Event Profile in Metastatic Spine Surgery: An Evidence-Based Approach to Target Wound Complications and Instrumentation Failure.

Systematic review. To identify risk factors and preventive methods for wound complications and instrumentation failure after metastatic spine surgery. We focused on two postoperative complications of metastatic spine tumor surgery: wound complications and instrumentation failure and preventive measures. We performed a systematic review of the literature from 1980 to 2015. The articles were analyzed for the presence of documented infection and/or wound complications and instrumentation failure. Forty articles met our inclusion criteria for wound complications and prevention. There is very low level of evidence that preoperative radiation, preoperative neurological deficit, revision procedures, and posterior approaches can contribute to wound complications (infections, wound dehiscence). There is very low level of evidence that plastic surgery soft tissue reconstruction, intrawound vancomycin powder, and percutaneous pedicle screws may prevent postoperative wound complications. Fourteen articles met our inclusion criteria for instrumentation failure. There is very low level of evidence that constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resection can contribute to implant failures. • For patients undergoing revision metastatic spine tumor surgery, plastic surgery should perform the soft tissue reconstruction (strong recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, plastic surgery may perform immediate soft tissue reconstruction (weak recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, intrawound vancomycin can be applied to decrease the risk of postoperative wound infections (weak recommendation/very low quality of evidence).• For patients undergoing metastatic spine tumor surgery, percutaneous pedicle screws can be placed to decrease the risk of postoperative wound complications (weak recommendation/very low quality of evidence).• Instrumentation failure risk factors include constructs greater than six levels, positive sagittal balance, preoperative radiation, and history of chest wall resections (weak recommendation/very low quality of evidence). N/A.

Adverse events in emergency oncological spine surgery: a prospective analysis.

Most descriptions of spine surgery morbidity and mortality in the literature are retrospective. Emerging prospective analyses of adverse events (AEs) demonstrate significantly higher rates, suggesting underreporting in retrospective and prospective studies that do not include AEs as a targeted outcome. Emergency oncological spine surgeries are generally palliative to reduce pain and improve patients' neurology and health-related quality of life. In individuals with limited life expectancy, AEs can have catastrophic implications; therefore, an accurate AE incidence must be considered in the surgical decision-making process. The purpose of this study was to determine the true incidence of AEs associated with emergency oncological spine surgery. The authors carried out a prospective cohort study in a quaternary care referral center that included consecutive patients admitted between January 1, 2009, and December 31, 2012. Inclusion criteria were all patients undergoing emergency surgery for metastatic spine disease. AE data were reported and collected on standardized AE forms (Spine AdVerse Events Severity System, version 2 [SAVES V2] forms) at weekly dedicated morbidity and mortality rounds attended by attending surgeons, residents, fellows, and nursing staff. A total of 101 patients (50 males, 51 females) met the inclusion criteria and had complete data. Seventy-six patients (76.2%) had at least 1 AE, and 11 patients (10.9%) died during their admission. Intraoperative surgical AEs were observed in 32% of patients (9.9% incidental durotomy, 16.8% blood loss > 2 L). Transient neurological deterioration occurred in 6 patients (5.9%). Infectious complications in this patient population were significant (surgical site 6%, other 50.5%). Delirium complicated the postoperative period in 20.8% of cases. When evaluated in a rigorous prospective manner, metastatic spine surgery is associated with a higher morbidity rate than previously reported. This AE incidence must be considered by the patient, oncologist, and surgeon to determine appropriate management and preventative strategies to reduce AEs in this fragile patient population.

Role of Intraoperative Red Cell Salvage and Autologus Transfusion in Metastatic Spine Surgery: A Pilot Study and Review of Literature

Study DesignProspective cohort study.PurposeThere has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery.Overview of LiteratureThere is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer.MethodsSixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department.ResultsAmount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period.ConclusionsIn our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.

Tranexamic Acid for Hemostasis in the Surgical Treatment of Metastatic Tumors of the Spine

This is a retrospective study of sequential cohorts. To assess the efficacy of tranexamic acid in decreasing operative blood loss and the need for intraoperative transfusion in metastatic spine surgery. Significant published data have established the efficacy of antifibrinolytic drugs in limiting surgical bleeding during heart surgery and total joint replacement. One study in scoliosis suggested benefit in spine surgery as well. During a 6-month trial period, 14 patients with spine cancer undergoing palliative intralesional tumor excision and concomitant instrumentation to stabilize the spine in the hands of a single surgeon were administered tranexamic acid intraoperatively in the attempt to minimize operative blood loss. They were then compared to the immediately preceding 14 patients. Estimated operative blood loss was 1385 mL in the study group treated with tranexamic acid and 1815 mL in controls not receiving the drug, and was not found to be significantly decreased in this study. Control of operative bleeding in metastatic spine surgery can be problematical. Optimum protocol might include routine preoperative angiographic tumor embolization to decrease lesion vascularity in all cases, but angiography is not without risk. Noninvasive prophylaxis of tumor bleeding would have obvious desirable advantages but was, unfortunately, not achieved in this study.