Spinal Instability Neoplastic Score Score Research Articles

The Spinal Instability Neoplastic Score correlates with epidural spinal cord compression -a retrospective cohort of 256 surgically treated patients with spinal metastases

BackgroundBone metastases can compromise the integrity of the spinal canal and cause epidural spinal cord compression (ESCC). The Spinal Instability Neoplastic Score (SINS) was developed in order to evaluate spinal instability due to a neoplastic process. The SINS has reached wide acceptance among clinicans but its prognostic value is still controversial. The aim was to investigate the correlation between the SINS and ESCC and the association between SINS and ambulation before and survival after surgery.MethodsCorrelations were assessed between SINS and grades of ESCC in patients who underwent spine surgery for spinal metastases. CT and MRI were used to calculate SINS and the grades of ESCC respectively. Correlations were analyzed with the Spearman’s correlation test. Postoperative survival was estimated with Kaplan-Meier analysis and survival curves were compared with the log-rank test. The Cox proportional hazard model was used to assess the effect of prognostic variables including age, ambulation before surgery, SINS, and the Karnofsky Performance Status (KPS) as covariates.ResultsThe study included 256 patients (196 men and 60 women) with a median age of 70 (24–88) years. The mean SINS was 10. One hundred fifty-two patients (59%) had lost ambulation before surgery. One hundred and one patients had grades 0–2 and 155 patients had grade 3 according to the ESCC-scale. SINS correlated with the grades of ESCC (p = 0.001). The SINS score was not associated with ambulation before surgery (p = 0.63). The median postoperative survival was 10 months, and there was no difference in postoperative survival between the SINS categories (p = 0.25). The ability to walk before surgery and a high KPS were associated with longer postoperative survival.ConclusionSINS correlated with grades of ESCC, which implies that higher SINS may be considered as an indicator of risk for developing ESCC. The SINS was not associated with ambulation before or survival after surgery.

The Truly Intermediate Subgroup Within the SINS “Potentially Unstable” Category: The Matryoshka Doll Phenomenon

A significant dilemma exists for the surgical plan of spinal metastases with a spinal instability neoplastic score (SINS) of 7-12. Our aim is to trim down this range of "potential instability" and find a virtual cut-off value for instrumentation. We performed a retrospective study on 60 patients who underwent surgical intervention for vertebral metastasis. They were segregated into 'instrumented' and "noninstrumented" groups. The primary endpoint of the study was to see whether surgical stabilization was done. Although univariate analysis showed the overall SINS score, involvement of posterior elements, and mechanical pain to be the factors that significantly affected our decision making in favor of stabilization, only the SINS score was found to be statistically significant on multivariate analysis. On plotting the proportion of patients undergoing stabilization at each SINS score we found the curves to crossover between SINS 8 and 9, ran almost parallel to each other at values 9 and 10 and then seemed to diverge from each other significantly at values above 10. Taking SINS 9 as the cut-off value above which instrumentation is advised, the receiver operating characteristic curve had a sensitivity of 67.57% (95% confidence interval 50.21% to 81.99%) and specificity of 73.91% (95% confidence interval 51.59% to 89.77%). The area under the curve was 0.79 (0.67-0.91). SINS 9-10 seems to be the actual ambiguous subset in the wider subgroup of the 'potentially unstable' category SINS 7-12, like a 'Matryoshka doll'. A SINS value of 9 can be seen as a cut-off value for instrumentation.

Vertebral Compression Fracture After Spine Stereotactic Body Radiotherapy: The Role of Vertebral Endplate Disruption.

Vertebral compression fracture (VCF) is a common, but serious toxicity of spinal stereotactic body radiotherapy (SBRT). Several variables that place patients at high risk of VCF have previously been identified, including advanced Spinal Instability Neoplastic Score (SINS), a widely adopted clinical decision criterion to assess spinal instability. We examine the role of tumoral endplate (EP) disruption in the risk of VCF and attempt to incorporate it into a simple risk stratification system. This study was a retrospective cohort study from a single institution. Demographic and treatment information was collected for patients who received spinal SBRT between 2013 and 2019. EP disruption was noted on pre-SBRT computed tomography scan. The primary end point of 1-year cumulative incidence of VCF was assessed on follow-up MRI and computed tomography scans at 3-month intervals after treatment. A total of 111 patients were included. The median follow-up was 18 months. Approximately 48 patients (43%) had at least one EP disruption. Twenty patients (18%) experienced a VCF at a median of 5.2 months from SBRT. Patients with at least one EP disruption were more likely to experience VCF than those with no EP disruption (29% vs 6%, P < .001). A nomogram was created using the variables of EP disruption, a SINS of ≥7, and adverse histology. Patients were stratified into groups at low and high risk of VCF, which were associated with 2% and 38% risk of VCF ( P < .001). EP disruption is a novel risk factor for VCF in patients who will undergo spinal SBRT. A simple nomogram incorporating EP disruption, adverse histology, and SINS score is effective for quickly assessing risk of VCF. These data require validation in prospective studies and could be helpful in counseling patients regarding VCF risk and referring for prophylactic interventions in high-risk populations.

Fracture rate after conventional external beam radiation therapy to the spine in multiple myeloma patients

Background ContextConventional external beam radiation therapy (cEBRT) is used in multiple myeloma (MM) to treat severe pain, spinal cord compression, and disease-related bone disease. However, radiation may be associated with an increased risk of vertebral compression fractures (VCFs), which could substantially impair survival and quality of life. Additionally, the use of the Spinal Instability Neoplastic Score (SINS) in MM is debated in MM. PurposeTo determine the incidence of VCFs after cEBRT in patients with MM and to assess the applicability of the SINS score in the prediction of VCFs in MM. Study DesignRetrospective multicenter cohort study. Patient SampleMM patients with spinal myeloma lesions who underwent cEBRT between January 2010 and December 2021. Outcome MeasuresFrequency of new or progressed VCFs and subdistribution hazard ratios for potentially associated factors. MethodsPatient and treatment characteristics were manually collected from the patients’ electronic medical records. Computed tomography (CT) scans from before and up to 3 years after the start of radiation were used to score radiographic variables at baseline and at follow-up. Multivariable Fine and Gray competing risk analyses were performed to evaluate the diagnostic value of the SINS score to predict the postradiation VCF rate. ResultsA total of 127 patients with 427 eligible radiated vertebrae were included in this study. The mean age at radiation was 64 years, and 66.1% of them were male. At the start of radiation, 57 patients (44.9%) had at least one VCF. There were 89 preexisting VCFs (18.4% of 483 vertebrae). Overall, 39 of 127 patients (30.7%) reported new fractures (number of vertebrae (n)=12) or showed progression of existing fractures (n=36). This number represented 11.2% of all radiated vertebrae. Five of the 39 (12.8%) patients with new or worsened VCFs received an unplanned secondary treatment (augmentation [n=2] or open surgery [n=3]) within 3 years. Both the total SINS score (SHR 1.77; 95% confidence interval (CI) 1.54–2.03; p<.001) and categorical SINS score (SHR 10.83; 95% CI 4.20–27.94; p<.001) showed an independent association with higher rates of new or progressed VCFs in adjusted analyses. The use of bisphosphonates was independently associated with a lower rate of new or progressed VCFs (SHR 0.47 [95% CI 0.24–0.92; p=.027]). ConclusionsThis study demonstrated that new or progressed VCFs occurred in 30.7% of patients within 3 years, in a total of 11.2% of vertebrae. The SINS score was found to be independently associated with the development or progression of VCFs and could thus be applied in MM for fracture prediction and possibly prevention.

Effectiveness of gelatin matrix with human thrombin for reducing blood loss in palliative decompressive surgery with posterior spinal fusion for metastatic spinal tumors

BackgroundThis study aimed to investigate the effect of gelatin matrix with human thrombin (GMHT) on blood loss and survival time in patients with metastatic spinal tumors treated with palliative decompression surgery with posterior spinal fusion. MethodsWe retrospectively reviewed 67 consecutive patients with metastatic spinal tumors who underwent palliative decompression surgery with posterior spinal fusion. We compared patients in whom GMHT was not used during surgery with those in whom GMHT was used. The following baseline characteristics were evaluated: age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, Karnofsky Performance Status score, Charlson comorbidities index score, the percentage of patients who received perioperative chemotherapy, main tumor level, Frankel category, revised Tokuhashi score, spinal instability neoplastic score (SINS), number of fusion segments, operation time, intraoperative blood loss, drainage blood loss, red blood cell transfusion, hemoglobin level, total protein (TP), albumin values, total blood loss (TBL), hidden blood loss, postoperative bed rest and postoperative survival time. Perioperative complications were assessed. ResultsAge, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, CCI score, main level of tumors, SINS score, preoperative Tokuhashi score and number of fusion segments did not differ significantly between the two groups. Operation time, intraoperative blood loss, postoperative drainage blood loss, and TBL were significantly decreased in the group with GMHT than in the group without GMHT. The total number of perioperative complications was significantly lesser in the group with GMHT than in the group without GMHT. The median postoperative survival time was significantly longer in the GMHT group than in the group without GMHT. ConclusionGMHT should be considered a valid option for the treatment of patients with metastatic spinal tumors with a short life expectancy.

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

85. The neurology stability epidural compression assessment: a new score to establish the need for surgery in spinal metastases

113. Correlation between the spinal instability neoplastic score (SINS) and patient reported outcomes

<h3>BACKGROUND CONTEXT</h3> The spinal instability neoplastic score (SINS) is used to define neoplastic-related spinal instability. Mechanical instability is one of the criteria for surgical intervention in patients with spinal metastases; however, data are limited regarding the association between mechanical instability and patient reported outcomes (PROs). <h3>PURPOSE</h3> The objective of this study was to investigate the correlation between the SINS score, individual components of the SINS score and patient reported health related quality of life. <h3>STUDY DESIGN/SETTING</h3> An international multicenter prospective observational study was conducted by the AOSpine Knowledge Forum Tumor on patients who underwent treatment for spinal metastases. <h3>PATIENT SAMPLE</h3> Patients who underwent treatment for spinal metastases, treated either with radiotherapy alone or surgery with or without adjuvant radiotherapy were eligible for inclusion in the observational cohort study. <h3>OUTCOME MEASURES</h3> Data pertaining to demographics, tumor and treatment information were prospectively collected. Patient-reported outcomes were evaluated at baseline, 6 weeks and 12 weeks post-treatment with the SF-36, SOSGOQ, EQ-5D. The SINS score was assessed using routine diagnostic imaging. <h3>Methods</h3> The Spearman's rank correlation coefficient was used to assess the association between SINS, PRO at baseline and change in PROs. An analysis of variance was performed to detect the important factors on SOSGOQ2.0 total score. <h3>RESULTS</h3> A total of 307 patients, including 174 patients who underwent surgery+/- radiotherapy and 133 patients who underwent radiotherapy were eligible for analyses. In the surgery+/- radiotherapy group, 18 patients were classified as having a stable lesion (SINS 0-6), 118 as potentially unstable (SINS 7-12), and 38 as unstable (SINS 13-18) as compared to 55 stable, 71 potentially unstable, and 7 unstable lesions in the radiotherapy-alone group. At baseline, the total SINS score and the presence of mechanical pain was significantly associated with the SOSGOQ pain domain (r=-0.519, P<0.001) and the NRS pain score (r=0.445, P<0.001) for all patients. The presence of mechanical pain demonstrated to be moderately associated with a positive change in PROs at 12 weeks post-treatment. In a multivariate model, SINS demonstrated the greatest impact (P<0.001) on the SOSGOQv2.0 at baseline as compared to other variables. <h3>Conclusions</h3> Spinal instability, as defined by the SINS score, significantly correlated with PROs at baseline and change in PROs post-treatment. Mechanical pain, as a single SINS component, showed the highest correlations with PROs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Correlation Between the Spinal Instability Neoplastic Score (SINS) and Patient Reported Outcomes.

International multicenter prospective observational cohort study on patients undergoing radiation +/- surgical intervention for the treatment of symptomatic spinal metastases. To investigate the association between the total Spinal Instability Neoplastic Score (SINS), individual SINS components and PROs. Data regarding patient demographics, diagnostics, treatment, and PROs (SF-36, SOSGOQ, EQ-5D) was collected at baseline, 6 weeks, and 12 weeks post-treatment. The SINS was assessed using routine diagnostic imaging. The association between SINS, PRO at baseline and change in PROs was examined with the Spearmans rank test. A total of 307 patients, including 174 patients who underwent surgery+/- radiotherapy and 133 patients who underwent radiotherapy were eligible for analyses. In the surgery+/- radiotherapy group, 18 (10.3%) patients with SINS score between 0-6, 118 (67.8%) with a SINS between 7-12 and 38 (21.8%) with a SINS between 13-18, as compared to 55 (41.4%) SINS 0-6, 71(53.4%) SINS 7-12 and 7 (5.2%) SINS 13-18 in the radiotherapy alone group. At baseline, the total SINS and the presence of mechanical pain was significantly associated with the SOSGOQ pain domain (r = -0.519, P < 0.001) and the NRS pain score (r = 0.445, P < 0.001) for all patients. The presence of mechanical pain demonstrated to be moderately associated with a positive change in PROs at 12 weeks post-treatment. Spinal instability, as defined by the SINS, was significantly correlated with PROs at baseline and change in PROs post-treatment. Mechanical pain, as a single SINS component, showed the highest correlations with PROs.

Prognostic factors and its predictive value in patients with metastatic spinal cancer.

BACKGROUNDThe spine is the most common location of metastatic diseases. Treating a metastatic spinal tumor depends on many factors, including patients’ overall health and life expectancy. The present study was conducted to investigate prognostic factors and clinical outcomes in patients with vertebral metastases. AIMTo investigate prognostic factors and their predictive value in patients with metastatic spinal cancer. METHODSA retrospective analysis of 109 patients with metastatic spinal cancer was conducted between January 2015 and September 2017. The prognoses and survival were analyzed, and the effects of factors such as clinical features, treatment methods, primary lesions and affected spinal segments on the prognosis of patients with metastatic spinal cancer were discussed. The prognostic value of Frankel spinal cord injury functional classification scale, metastatic spinal cord compression (MSCC), spinal instability neoplastic score (SINS) and the revised Tokuhashi score for prediction of prognosis was explored in patients with metastatic spinal tumors. RESULTSAge, comorbidity of metastasis from elsewhere, treatment methods, the number of spinal tumors, patient’s attitude toward tumors and Karnofsky performance scale score have an effect on the prognosis of patients (all P < 0.05). With respect to classification of spinal cord injury, before operation, the proportion of grade B and grade C was higher in the group of patients who died than in the group of patients who survived, and that of grade D and grade E was lower in the group of patients who died than in the group of patients who survived (all P < 0.05). At 1 mo after operation, the proportion of grade A, B and C was higher in the group of patients who died than in the group of patients who survived, and that of grade E was lower in patients in the group of patients who died than in the group of patients who survived (all P < 0.05). MSCC occurred in four (14.3%) patients in the survival group and 17 (21.0%) patients in the death group (P < 0.05). All patients suffered from intractable pain, dysfunction in spinal cord and even paralysis. The proportion of SINS score of 1 to 6 points was lower in the death group than in the survival group, and the proportion of SINS score of 7 to 12 points was higher in the death group than in the survival group (all P < 0.05). The proportion of revised Tokuhashi score of 0 to 8 points and 9 to 11 points were higher in the death group than in the survival group, and the proportion of revised Tokuhashi score of 12 to 15 points was lower in the death group than in the survival group (all P < 0.05). Frankel spinal cord injury functional classification scale, MSCC, SINS and revised Tokuhashi score were important factors influencing the surgical treatment of patients with metastatic spinal cancer (all P < 0.05). CONCLUSIONFrankel spinal cord injury functional classification scale, MSCC, SINS and revised Tokuhashi score were helpful in predicting the prognosis of patients with metastatic spinal cancer.

Can MRI be used as a safe and expedient option for calculating Spinal Instability Neoplastic Score for patients with metastatic spinal cord compression?

The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient's MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J2021;103-B(5):971-975.

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

Vertebral 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. Cases 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. Among 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%. As 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.

Patient Characteristics Following Surgery for Spinal Metastases: A Multicenter Retrospective Study.

ObjectivesTo summarize the epidemiological characteristics of patients following surgery for spinal metastases retrospectively and make a univariate analysis to identify independent variables that could affect the operation decision making.MethodsThis was a multicenter retrospective review of patients with spinal metastasis who were treated with surgery from 1 January 2007 to 31 July 2019. Basic clinical data were analyzed retrospectively by univariate analysis to identify independent variables that could affect the decision of operation modalities, including gender, age, spinal metastatic site, Frankel score, Karnofsky performance score (KPS), spinal instability neoplastic score (SINS), visual analogue scale (VAS), Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, primary tumor, extraspinal metastasis, visceral metastasis, and bone lesion (osteolytic, osteoblastic or mixed).ResultsA total of 580 patients including 332 males and 248 females were enrolled in the study with an average age of 58.26 years old (range, 13–86 years old). The most common spinal metastatic level was the thoracic vertebra (190 [32.76%]), followed by the lumbar vertebra (146 [25.17%]), cervical vertebra (47 [8.10%]), and sacral vertebra (35 [6.03%]). Metastases involving more than two sites of the cervical, thoracic, lumbar, and sacral vertebrae arose in 162 (27.93%) patients. For primary tumor, there were 198 (34.14%) cases of lung cancer, 41 (7.07%) cases of kidney cancer, 39 (6.72%) cases of breast cancer, 38 (6.55%) cases of gastrointestinal cancer, 35 (6.03%) cases of lymphoma and myeloma, 25 (4.31%) cases of prostate cancer, 24 (4.14%) cases of liver cancer, 23 (3.97%) cases of mesenchymal tissue sarcoma, 20 (3.45%) cases of thyroid cancer, and 84 (14.48%) cases were tumor with unknown origin. Sixty‐three (10.86%) patients received minimally invasive surgery, 460 (79.31%) patients received palliative surgery, and the remaining 57 (9.83%) received tumor resection. According to the univariate analysis, the KPS score, SINS score, VAS score, Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, and bone lesion (osteolytic, osteoblastic or mixed) were independent and favorable factors affecting the surgery modalities.ConclusionsSurgical treatment for spinal metastases was mainly to relieve pain, rebuild spinal stability, improve nerve function, control local tumors, and improve the quality of life of patients. For middle‐aged and elderly patients with good general conditions, severe pain, spinal pathological fracture, spine instability and without urinary and fecal incontinence, early surgical treatment should be actively carried out.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Classifications in Brief: The Spinal Instability Neoplastic Score.

SINS Score and Stability: Evaluating the Need for Stabilization Within the Uncertain Category

The Spinal Instability Neoplastic Score (SINS) is widely used to assess mechanical instability in metastatic spine disease. We sought to identify a cutoff within the "potentially unstable" category, above which lesions were more likely than not to be stabilized. We retrospectively reviewed all patients consulted for metastatic spine disease over a 1-year period. Patients were included if they were neurologically intact and had complete medical records, including preoperative imaging of every tumor-involved level. Examined variables included epidural spinal cord compression, SINS, revised Tokuhashi grade, age at consultation, and Karnofsky Performance Status. The primary endpoint was whether or not the lesions were stabilized. The study cohort comprised 51 patients (average age, 61 ± 2 years) with a total of 436 lesions; 50.5% were lytic, and 31.4% were blastic. The most common primaries were lung (n= 12), breast (n= 10) and prostate (n= 8). The median SINS across all lesions was 5. In both lesion- and patient-based analysis, a SINS ≥10 portended a >50% probability of undergoing stabilization; only 11% of all patients with a SINS ≤9 underwent instrumented fusion. Multivariable analysis demonstrated that SINS (odds ratio [OR], 2.44; P < 0.01) and Karnofsky Performance Status (OR, 1.10; P < 0.01) were independent predictors of stabilization. For vertebrae affected by metastatic disease, the decision to stabilize remains dependent on both the radiographic lesion properties and the patient's clinical picture. However, our results suggest that lesions with a SINS of ≤9 might not require stabilization.

Intra- and interobserver reliability of the Spinal Instability Neoplastic Score system for instability in spine metastases: a systematic review and meta-analysis.

Mechanical instability is one of the two main indications for surgical intervention in patients with metastatic spine disease. Since its publication in 2010, the Spinal Instability Neoplastic Score (SINS) has been the most commonly used means of assessing mechanical instability. To prove clinically valuable though, diagnostic tests must demonstrate consistency across measures and across observers. Here we report a systematic review and meta-analysis of all prior reports of intraobserver and interobserver reliability of the SINS score. To identify articles, we queried the PubMed, CINAHL, EMBASE, Cochrane, and Web of Science databases for all full-text English articles reporting interobserver or intraobserver reliability for the SINS score, category, or a domain of the SINS score. Articles reporting confidence intervals for these metrics were then subjected to meta-analysis to identify pooled estimates of reliability. Of 167 unique studies identified, seven met inclusion criteria and were subjected to qualitative review and meta-analysis. Intraobserver reliability for SINS score was found to be near perfect [estimate =0.815; 90% CI (0.661-0.969)] and interobserver reliability was substantial [0.673; (0.227-1.12)]. Intraobserver and interobserver reliability among spine surgeons was significantly better than reliability across all observers (both P<0.0001). Qualitative analysis suggested that increased surgeon experience may be associated with greater intraobserver and interobserver reliability among spine surgeons. On the whole, meta-analysis of the available literature suggests SINS to have good intraobserver and interobserver reliability, giving it the potential to be a valuable guide to the management of patients with spinal metastases. Further research is required to demonstrate that SINS score correlates with the clinical decision to stabilize.

A Multicenter Prospective Cohort Study Evaluating Quality of Life after Radiation or Surgery for Potentially Unstable Spinal Metastases

The purpose of this study was to compare health related quality of life (HRQOL) outcomes for surgery and/or radiotherapy in patients with potentially unstable spinal metastases. A multicenter prospective observational study specific to patients undergoing radiation and/or surgical intervention for the treatment of symptomatic spinal metastases was conducted. Patients with potentially unstable spinal metastases, defined as a Spinal Instability Neoplastic Score (SINS) between 7 and 12, were included. HRQOL scores were modeled and compared between treatment groups using mixed effect models with adjustment for baseline differences. In total, 120 patients were treated with surgery +/- radiotherapy and 82 with radiotherapy alone. At baseline, surgically treated patients presented with worse performance status, HRQOL, numeric rating scale (NRS) pain scores, and a greater median SINS score [10 versus 8 in those treated with radiotherapy alone (p<0.001)]. Significant differences in the distribution of individual SINS factors were also observed between both treatment groups. From baseline to 12 weeks post-treatment, surgically treated patients experienced a greater improvement in HRQOL with a 12-point increase in adjusted mean SOSGOQ2.0 score (95%CI 5.1 – 19.0, p<0.001) as compared to a 6.2-point gain in those treated with radiotherapy alone (95%CI -2.2 – 14.6, p=0.352). In addition, the gain in the SOSGOQ2.0 score exceeded the minimal clinically important difference threshold in 63% of the surgical cohort as compared to 44% in the radiotherapy alone cohort (p=0.017). For patients presenting with potentially unstable spinal metastases, treatment with surgery +/- radiotherapy resulted in greater and clinically meaningful changes in HRQOL as compared to patients treated with radiotherapy alone. However, these results must be taken into context according to differences in individual SINS factors and grouping of SINS factors that comprise the individual cohorts.

Anterolateral Cervical Kyphoplasty for Metastatic Cervical Spine Lesions.

Study DesignRetrospective case series.PurposeTo evaluate the clinical and radiological efficacy of anterolateral kyphoplasty for cervical spinal metastasis.Overview of LiteratureAlthough the spine is the third most common site of tumor metastasis, the cervical spine is the least commonly affected (incidence, 10%–15%). Surgical decompression is highly challenging because of the proximity of neural and vascular elements. Kyphoplasty for cervical spine metastasis has been described in small case reports with promising results.MethodsRetrospective analysis of a prospective collected single-center spine metastasis database was done for cervical kyphoplasty cases. Data pertaining to age, sex, primary tumor diagnosis, modified Tokuhashi score, Spinal Instability Neoplastic Score (SINS), preoperative Visual Analog Scale (VAS) score, and analgesic medication were extracted. Postoperative data included VAS score at postoperative day 1, duration of hospitalization, self-reported functional outcome, and VAS score at the last follow-up.ResultsEleven patients (mean age, 62.5 years) with cervical spine metastases were treated with 15-level kyphoplasty. Mean Tokuhashi score was 8.1, and mean SINS was 7.85. Mean preoperative pain score was 7.1, and 82% of patients used opioid analgesics. Mean total bleeding volume was 100 mL. Mean complication-free length of stay was 2.6 days with a decrease in postoperative pain (VAS score=2.8, p <0.05). There was a 56% decrease in opioid dosage and the number of consumed analgesics (1.09, p =0.004). Eighty-two percent of the patients reported excellent improvement at the last follow-up self-assessment.ConclusionsTo our knowledge, this case series represents the largest series of vertebral augmentation using balloon kyphoplasty for cervical spinal metastasis. This technique is associated with low postoperative complications as well as significant decrease in pain, use of opioids, and length of hospital stay. The main indications for vertebral kyphoplasty are lytic lesions of the cervical spine, painful lesions refractory to medical treatment, SINS score of 6–10, and absence of posterior wall defect.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Improving Quality of Life for Patients with Tumors: 81. Choice of treatment in spinal metastatic disease with indeterminate instability (SINS 7-12): impact on survival and preservation of ambulatory status

BACKGROUND CONTEXT The management of spinal metastasis has evolved with the development of improved radiation delivery methods and surgical techniques. The Spinal Instability Neoplastic Score (SINS) provides guidance on treatment for spinal instability. However, the best treatment modality for neurologically intact patients with indeterminate instability (SINS 7–12) remains unclear. PURPOSE The purpose of this study was to compare length of survival (LOS) and preservation of ambulatory status (PAS) in this patient population treated by three different techniques. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE N=60 20 patients surgery + EBRT 20 patients XRT along 20 patients kyphoplasty +/− EBRT. OUTCOME MEASURES LOS - length of survival, PAS - preservation of ambulatory status. METHODS We queried our institution's database for neurologically intact patients treated for spinal metastatic disease with a SINS of 7-12. The cohort was stratified by treatment approach: external beam radiation (EBRT), surgery + EBRT (S+E), and kyphoplasty +/− EBRT (K). Demographic, clinical, and outcomes data were compared using Chi Squared tests and ANOVA. Kaplan-Meier analysis with the log-rank test was used to assess differences in LOS and PAS. Cox proportional hazard models were used to assess adjusted survival and time to loss of ambulation. RESULTS Sixty cases were included in our analysis (EBRT n=20; S+E n=20; Kn=20). There was no significant difference in gender, age or cancer type across the treatment groups. Tokuhashi scores were greater in the S+E group (p=.03). Kaplan Meier analysis revealed that there was no significant difference in LOS and PAS across the treatment arms (p=.10, p=.07). When adjusting these models for age, gender, SINS and Tokuhashi score; Toskuhashi score was associated with improved outcomes (LOS HR: 0.76 to 0.94, p=.002; PAS HR: 0.78 to 0.95, p=.005). CONCLUSIONS The choice of treatment for neurologically intact patients with indeterminate instability does not impact LOS or PAS. Patients with greater preoperative Tokuhashi scores had statistically longer LOS and PAS. When spinal instability and neurological status do not clearly guide treatment, the Tokuhashi score provides the best predictor in management decision-making. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Improving Quality of Life for Patients with Tumors: 76. A multicenter prospective cohort study evaluating quality of life after radiation or surgery for potentially unstable spinal metastases

BACKGROUND CONTEXT Optimal treatment selection between surgery and radiotherapy for patients with potentially unstable spinal metastases is unknown. PURPOSE The purpose of this study was to compare HRQOL outcomes for surgery +/− radiotherapy to radiotherapy alone in patients with potentially unstable spinal metastases. STUDY DESIGN/SETTING The AOSpine Knowledge Forum Tumor conducted an international multicenter prospective observational study. PATIENT SAMPLE Patients were eligible for inclusion if they were between 18 and 75 years of age and underwent surgery (+/− radiotherapy) or radiotherapy alone for spinal metastases. For this analysis, only patients with potentially unstable spinal metastases, defined by a spinal instability neoplastic score (SINS) between 7 and 12, were included. OUTCOME MEASURES Health related quality of life (HRQOL) was evaluated at baseline and during following up at fixed time points with the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0), SF-36, EQ-5D and NRS pain score. METHODS The two treatment groups were compared at baseline for differences in demographics, individual SINS factors, grouping of SINS factors and HRQOL. HRQOL scores were modeled over time using mixed effect models with adjustment for differences in baseline characteristics. RESULTS Between August 2013 and May 2017, 202 patients with potential spinal instability were enrolled at 10 tertiary care spine centers across North America and Europe. In total 120 patients were treated with surgery +/− radiotherapy and 82 with radiotherapy alone. At baseline, patients who underwent surgery +/− radiotherapy had a lower performance status, lower HRQOL scores, higher NRS pain scores and a higher median SINS score (10 vs. 8) compared to patients treated with radiotherapy alone. Surgically treated patients experienced a greater and clinically significant increase in adjusted mean SOSGOQ2.0 score (+12.0, 95%CI 5.1–19.0, p CONCLUSIONS Patients treated with surgery +/− radiotherapy for potentially unstable spinal metastases, according to the SINS, experienced greater and clinically significant differences in HRQOL as compared to patients treated with radiotherapy alone. Baseline differences in the individual SINS factors and the grouping of the SINS factors, however, illustrate distinct differences between the two treatment groups. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

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

OBJECTIVE Delayed 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). METHODS The 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. RESULTS Among 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. CONCLUSIONS In 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.