Spinal Metastases In Patients Research Articles

Assessment of survival prediction after surgery in spinal metastases patients using the Global Spine Study Tumor Group (GSTSG) risk calculator; an external validation from a tertiary cancer hospital.

We aim to validate the Global Spine Tumor Study Group (GSTSG) score compared to previous prognostic scoring systems in spinal metastasis. 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 24months. The overall survival rate was reported using the Kaplan-Meier survival curve. 248 spinal metastasis patients were included. The mean age was 59.23 ± 12.55years. The mean duration of follow-up time was 470.29 ± 441.98days. 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 3months (both AUC of GSTSG and SORG = 0.76) and higher than modified Tokuhashi and Tomita score at 12months (AUC of GSTSG = 0.78, SORG = 0.71, Tomita = 0.64, and modified Tokuhashi = 0.61, respectively). 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 24months.

The Magnetic Resonance Imaging of the Psoas Muscle Area as the Prognostic Factor for Survival and Adverse Events in Spinal Metastasis Surgery.

Retrospective study. This study aimed to evaluate the ability of the mortality and adverse events prediction following metastatic spinal surgery of MRI-based cross-sectional psoas muscle area (PMA). A retrospective chart review, 120 patients who had undergone metastatic spinal surgery were included. The cross-sectional area identified the PMA under MR-imaging at the L3 or L4 pedicle level, which was classified into 3 tertiles. We used univariate and multivariate cox proportional hazard regression to assess whether PMA was associated with 30-day, 90-day, 1-year, and overall mortality. The small psoas tertile group populations had a higher mortality rate than the large psoas tertile group. PMA in T1 and T2 had a probability of a higher 90-d mortality rate than PMA in T3 (T1 VS T3: P = .29 and T2 VS T3: P = .12). The median survival time was 7months, 9months, and 10months in PMA T1, T2, and T3, respectively. PMA in tertile 2 had a significantly higher mortality rate of 38% compared to PMA in tertile 3 (HR 1.38, 95% CI .83-2.32, P = .02). Considering PMA as a continuous variable, every 1mm2 increment of PMA resulted in the increase survivorship of 1% (HR .99 with 95% CI .99-1). The MRI-based cross-sectional PMA tends to predict the 90-d mortality rate and overall mortality rate in spinal metastasis patients who underwent spinal surgery. The PMA should be considered one of the prognostic factors in the treatment of metastatic spinal patients.

Development and internal validation of machine-learning models for predicting survival in patients who underwent surgery for spinal metastases.

A retrospective study. This study aimed to develop machine-learning algorithms for predicting survival in patients who underwent surgery for spinal metastasis. This study develops machine-learning models to predict postoperative survival in spinal metastasis patients, filling the gaps of traditional prognostic systems. Utilizing data from 389 patients, the study highlights XGBoost and CatBoost algorithms̓ effectiveness for 90, 180, and 365-day survival predictions, with preoperative serum albumin as a key predictor. These models offer a promising approach for enhancing clinical decision-making and personalized patient care. A registry of patients who underwent surgery (instrumentation, decompression, or fusion) for spinal metastases between 2004 and 2018 was used. The outcome measure was survival at postoperative days 90, 180, and 365. Preoperative variables were used to develop machine-learning algorithms to predict survival chance in each period. The performance of the algorithms was measured using the area under the receiver operating characteristic curve (AUC). A total of 389 patients were identified, with 90-, 180-, and 365-day mortality rates of 18%, 41%, and 45% postoperatively, respectively. The XGBoost algorithm showed the best performance for predicting 180-day and 365-day survival (AUCs of 0.744 and 0.693, respectively). The CatBoost algorithm demonstrated the best performance for predicting 90-day survival (AUC of 0.758). Serum albumin had the highest positive correlation with survival after surgery. These machine-learning algorithms showed promising results in predicting survival in patients who underwent spinal palliative surgery for spinal metastasis, which may assist surgeons in choosing appropriate treatment and increasing awareness of mortality-related factors before surgery.

Effect of radiotherapy on local control and overall survival in spinal metastasis of non-small-cell lung cancer after surgery and systemic therapy.

Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS. A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis. Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC. Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients.

Clinical and oncologic outcomes of posterior only total en bloc spondylectomy for spinal metastasis involving third lumbar vertebra: A case series.

A posterior-only total en bloc spondylectomy (TES) of the L3 level was deemed a highly intricate surgical procedure, necessitating the preservation of the L3 nerve root to prevent neurological deterioration. Despite bilateral preservation efforts of the L3 nerve roots, neurological deterioration proved unavoidable. This study aims to present the clinical, neurologic, and oncologic outcomes of spinal metastasis patients who underwent a posterior-only approach TES, encompassing the L3 vertebra. All patients with L3-involved spinal metastasis undergoing posterior TES between January 2018 and January 2022 were investigated. The primary outcomes considered were the local recurrence rate and manual muscle testing of the lumbar myotome. Secondary outcomes included Frankel neurological status, operative time, blood loss, perioperative and postoperative complications, and Eastern Cooperative Oncology Group score. Five patients with TES involving L3 (three females) met the inclusion criteria. All patients had solitary metastases (three in the lungs, 2 in the breasts). Postoperatively, all patients experienced weakness of the hip flexors, but they were able to ambulate independently 12 months after surgery. One patient exhibited adjacent segment (L2) disease progression and underwent corpectomy 18 months after TES. No local recurrences at the surgical site were detected on magnetic resonance imaging at the 1-year follow-up. Posterior-only TES for L3-involved vertebrae yielded excellent results in the local control of metastatic disease. Despite hip flexor weakness, all patients were able to regain independent ambulation after 12 months. TES can offer favorable clinical and oncological outcomes in patients with solitary spinal metastases.

Outcomes of Operated Cases of Central Nervous System Metastases at a Tertiary Cancer Hospital – An Analysis

Abstract Background: Recent advances in the treatment have increased the survival of patients with common cancers. As a result, the incidence of symptomatic central nervous system (CNS) metastases has increased over time. Although systemic therapies remain the mainstay of metastatic cancers, surgical treatment is often required for progressive neurological deficits and to buy time for other modalities to be effective. The present retrospective study aimed to analyze various demographic, neurological, and short-term survival outcomes among operated cases of symptomatic CNS metastases. Materials and Methods: All surgically treated symptomatic brain and spine metastasis patients between August 2018 and March 2022 were included in the study. Patients who underwent procedures for primary tumors of the brain and spine were excluded. The details of demographic and clinical profile, neurological data, surgical treatment, and short-term survival data were retrieved from hospital medical records and analyzed. Patients with motor deficits (power grade 3/5 or less) were analyzed to look for improvement in motor deficits after surgery. Results: The first 100 operated cases of symptomatic CNS metastases were reviewed. The mean age of presentation was 46.42 years (females – 44.28, males – 49.13). Breast malignancy was the most common source of primary overall (29%) and lung malignancy (15%) was second most common. A total of 53 brain surgeries and 47 spine surgeries were performed. Preoperative motor deficits were seen more commonly among spine metastases (30/47) than brain metastases (17/53) patients. Around 64% of patients who presented with neurological deficits (motor deficits) had improvement postsurgery. Such improvement from deficits was observed more in patients with spine metastases (23/30; 76.7%) than brain metastases (7/17; 41.2%). Conclusion: Neurosurgery has an important role in the management of CNS metastases, and timely surgical intervention in a selected group of symptomatic CNS metastases can improve the quality of life of the patients.

Delay of Surgery for Spinal Metastasis due to the COVID-19 Outbreak Affected Patient Outcomes.

The present study is to analyze the effects of the coronavirus disease 2019 (COVID 2019) outbreak and the subsequent lockdown on the outcomes of spinal metastasis patients. The study was a retrospective analysis of data from a prospective cohort study. All patients underwent surgical intervention for spinal metastases between January 2019 and December 2021 and had at least 3 months of postoperative follow-up. The primary outcome was overall mortality during the 4 different stages (pre-COVID-19 era, COVID-19 pandemic except in Taiwan, national lockdown, lifting of the lockdown). The secondary outcomes were the oncological severity scores, medical/surgical accessibility, and patient functional outcome during the 4 periods as well as survival/mortality. A total of 233 patients were included. The overall mortality rate was 41.20%. During the Taiwan lockdown, more patients received palliative surgery than other surgical methods, and no total en bloc spondylectomy was performed. The time from surgeon visit to operation was approximately doubled after the COVID-19 outbreak in Taiwan (75.97, 86.63, 168.79, and 166.91 hours in the 4 periods, respectively). The estimated survival probability was highest after the national lockdown was lifted and lowest during the lockdown. In the multivariate analysis, increased risk of mortality was observed with delay of surgery, with emergency surgery having a higher risk with delays above 33 hours, urgent surgery (below 59 and above 111 hours), and elective surgery (above 332 hours). The COVID-19 pandemic and related policies have altered daily clinical practice and negatively impacted the survival of patients with spinal metastases.

Safety and feasibility of ultra-long construct navigated minimally invasive spine surgery with adjuvant radiotherapy in extensive spinal metastasis : a comparative analysis

BackgroundOur study compares the outcomes of extensive spinal metastasis patients treated with Ultra-Long Construct Navigated Minimally Invasive Spine Surgery (UNMISS) with Adjuvant Radiotherapy to those receiving only radiotherapy. Spinal metastasis often necessitates interventions like radiotherapy, chemotherapy, or surgery, with an increasing trend towards surgical management. minimally invasive spine surgery has demonstrated advantages over traditional open surgery, with fewer complications and better postoperative outcomes. Radiotherapy continues as a standard for those unsuitable for surgery.MethodsThis retrospective study included extensive spinal metastasis patients treated between January 2017 and December 2020. We compared patients undergoing UNMISS in conjunction with radiotherapy to patients receiving radiotherapy alone, evaluating demographic data, disease characteristics, and treatment outcomes (VAS, survival) to establish statistical significance.ResultsTwenty-three patients were included in our study. Fourteen patients underwent UNMISS, and nine patients received radiotherapy alone. There was no difference in baseline characteristics of patients. The longest construct in our case series involved T1 to iliac. Both cohorts showed significant improvement in pain scores post-treatment (p = 0.01). However, the UNMISS group demonstrated significantly lower post-treatment VAS scores (p = 0.003), indicating enhanced pain relief. Survival outcomes did not differ significantly between the two groups.ConclusionThe UNMISS should be considered as an alternative treatment in a patient with symptomatic extensive spinal metastasis. The primary goal of this technique is to stabilize the multiple levels of spinal metastasis and decompression of the neural element if needed. This technique is safe and has a better outcome in pain improvement than the patient who received radiotherapy alone.

Six-Month Survivorship Prediction in Spinal Metastatic Patients by Oncologists Shows Reliable Prognostication.

A retrospective analysis of oncologist-provided prognoses vs actual survival outcomes of patients referred with Metastatic spinal cord compression (MSCC) to a supra-regional multidisciplinary team (MDT). Prognostic scoring systems, such as the revised Tokuhashi, are commonly used to help guide the treatment of MSCC. However, scoring systems do not accommodate for the improved outcomes of contemporary cancer therapy. Oncologist-provided prognoses play an important role in real world rapid decision making. There is a paucity of evidence assessing the accuracy of the oncologist-provided prognosis. We conducted a retrospective study to evaluate this. Data was captured between January 2015 and December 2018. Patients were split into 2 groups: Group 1 (prognosis estimated <6months) and Group 2 (prognosis estimated >6months). Median overall survival (mOS) and hazard ratio for death (HR) was assessed. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of the oncologist's prognosis. 829 patients were included. mOS in Group 1 was 5.8 months (95% CI 4.2-7.4m), and in Group 2 mOS was not reached. Log rank test gave a Chi2 of 131 (P < .001). Cox regression analysis revealed a HR of .30 (P < .001). Area under the ROC curve was 78%. Oncologist-provided prognosis is accurate in this cohort of unselected, consecutive MSCC patients. It reduced reliance on scoring systems that can become outdated. Given the rapid progress in cancer treatment, the oncologist's prognostic prediction is integral in efficient and effective MSCC management to help rapidly determine surgical candidacy.

Postoperative survival after lumbar instrumented surgery for metastatic spinal tumors: a nationwide population-based cohort analysis.

It is difficult to predict the expected survival after lumbar instrumented surgery for metastases owing to the difference among different cancer origins and the relatively short survival after surgery. The aim of this study is to analyze the postoperative survival period of lumbar spinal metastasis patients who underwent lumbar instrumented surgery. Data were collected from the Korean National Health Insurance Review and Assessment Service database. Patients who underwent lumbar spinal surgery with instrumentation between January 2011 and December 2015 for metastatic lumbar diseases were reviewed. The mean postoperative survival period of patients with metastatic lumbar cancer according to each primary cancer type was evaluated. A total of 628 patients were enrolled and categorized according to primary cancer type. The overall median survival rate was 1.11±1.30 years. The three most prevalent primary cancer groups were lung, hepatobiliary, and colorectal cancers, presenting relatively short postoperative survival rates (0.93±1.25, 0.74±0.75 and 0.74±0.88 years, respectively). The best postoperative survival period was observed in breast cancer (2.23±1.83 years), while urinary tract cancer showed the shortest postoperative survival period (0.59±0.69 years). The postoperative survival period of patients with lumbar metastatic spinal tumors according to different primary cancers after instrumented fusion was ˃1 year overall, with differences according to different primary origins. This result may provide information regarding the expected postoperative survival after instrumented surgery for lumbar spinal metastases.

Is it safe for the spinal metastasis patients with preoperative deep vein thrombosis to use low-molecular-weight heparin before surgery? A prospective study

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.

A novel scoring system incorporating sarcopenia to predict postoperative survival in spinal metastasis

BACKGROUND CONTEXTAs the prevalence of spinal metastasis rises, methods to predict survival will become increasingly important for clinical decision-making. Sarcopenia may be used to predict survival in these patients. PURPOSEThe purpose of this study to develop a prediction model incorporating sarcopenia for postoperative survival in patients with spinal metastasis. DESIGNRetrospective cohort study. PATIENT SAMPLEThis study included 200 patients who underwent operative intervention for spinal metastasis in our institution, a tertiary, academic spine center. OUTCOME MEASURESThe primary outcome measure was 1-year postoperative survival. The secondary outcome measures were 3-month and 6-month postoperative survival. METHODSClinicopathological and survivorship data was collated. Sarcopenia was defined using the L3 Psoas/Vertebral Body Ratio on cross-sectional CT. Independent predictors of postoperative survival were assessed by multiple logistic regression. RESULTSOverall 1-year postoperative survival was 50%. L3/Psoas ratio ≥1.5 (OR 6.2), albumin ≥35g/l (OR 3.0) and primary tumor type were found to be independent predictors of 3 month, 6 month and 1 year postoperative survival on multivariable analysis. Age at surgery, ambulatory status and mode of presentation were not independent predictors of survival. Variables were used to generate a new scoring system, ProgMets, to predict postoperative survival. The ProgMets system had greater correlation and higher area under the curve (AUC, 0.80) for 1-year survival than other scoring systems. CONCLUSIONSThis is the first model to incorporate sarcopenia to predict survival in spinal metastasis patients and has good prediction of survival compared to previous models. This tool may be increasingly useful for informed decision making for patients and surgeons.

The Identification of Risk Factors for Symptomatic Spinal Metastasis Onset: A Prospective Cohort Study of 128 Asymptomatic Spinal Metastasis Patients.

Background: Symptomatic spinal metastasis (SSM) decreases the activities of daily living (ADL) and quality of life of cancer patients. However, the risk factors for SSM onset remain unclear. This prospective cohort study aimed to statistically analyze the significant risk factors. Methods: From 2016 to 2018, 210 consecutive patients with spinal metastases were prospectively registered. Patients with SSM at the first consultation and those who were unable to be followed-up owing to poor general condition were excluded. The demographic factors (age, sex, primary cancer, performance status, and ADL), clinical factors (radiation therapy, chemotherapy, molecularly targeted drugs, and bone-modifying agents (BMAs)), and Spinal Neoplastic Instability Score (SINS) were evaluated. Multivariate analysis was performed to identify the risk factors for SSM onset. Furthermore, the threshold was calculated from the receiver operating characteristic curve using the Youden index. Results: Thirty-nine patients who presented with SSM at the first consultation and 43 patients who were unable to be followed-up owing to poor general condition were excluded. Finally, 128 asymptomatic patients were included. Thirty-seven patients (28.9%) developed SSM during the follow-up period. The total SINS (OR: 1.739; 95% CI: 1.345-2.250) was identified as the most significant factor. The cut-off value of the SINS was 9.5 (sensitivity: 67.6%; specificity: 83.5%). Twenty-five (62.5%) of the forty patients with a SINS ≥ 10 developed SSM within a mean of 5.5 months (95% CI: 1.17-9.83). Furthermore, all patients with a SINS ≥ 13 developed SSM (n = 5) within a mean of 1.37 months (95% CI: 0.0-3.01). Conclusions: This study identified the significant risk factors for SSM onset and the threshold of the SINS. If long-term survival is expected, patients with a SINS ≥ 10 should be considered for intervention to prevent SSM.

Efficacy and safety of erythropoietin inisolated spinal metastasis patients withtotal en bloc spondylectomy surgery: acase-control study.

The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS). From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused. The average follow-up duration was 38.13months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011). Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.

Survival and Functional Outcomes after Surgical Treatment for Spinal Metastasis in Patients with a Short Life Expectancy.

This study aimed to analyze the survival and functional outcome after surgery in spinal metastasis patients with a short life expectancy and to compare the baseline characteristics based on 3-month survival. A total of 492 surgical treatment cases with a preoperative revised Tokuhashi score ≤ 8were reviewed. Median survival was calculated and Kaplan−Meier analysis was used to analyze the survival rates at 6 months, 1 year, and 2 years postoperatively. The surgical period was divided into three time frames to examine the time trends. For the functional outcome, Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was analyzed. This study categorized subjects based on 3-month survival and compared the baseline characteristics. The median overall survival was 10.6 months. The 2013−2020 period showed a significantly better median survival than the other two periods (p < 0.001). Lung and kidney cancers showed a significant survival improvement in 2013−2020 (p < 0.001). Patients with ECOG-PS ≤ 2 increased from 37.4% preoperatively to 63.7% postoperatively (p < 0.001). There were significantly more cases of preoperative favorable performance status, slow and moderate growth cancers, and chemotherapy after surgery in the survival ≥3 months group. Depending on the type of primary cancer, surgery can be considered even in spinal metastasis patients with a short life expectancy, particularly those with a good performance status.

Spinal Metastases without Pedicle Signs on Radiograph and their Associated Clinical and Radiological Features.

The pedicle sign is a radiographic indicator of spinal metastases. However, it is not only the pedicle sign that is important in radiographic diagnosis of bone metastases. In the present study, the radiological features of symptomatic spinal metastases in patients without the pedicle sign were retrospectively examined. Among 186 patients with symptomatic spinal metastases who visited our department between January 1, 2011, and December 31, 2017, 64 without the pedicle sign and with available computed tomography (CT) and magnetic resonance imaging (MRI) data in the first visit were enrolled and their data were analyzed. One author evaluated radiographs for findings suggestive of spinal metastases, CT to assess bone destruction, and MRI to evaluate the extent of lesions. Clinical variables were also examined and compared between patients with and without bone changes on radiography. Bone changes strongly suggesting bone metastasis, other than the pedicle sign, were observed in 31 out of 64 patients: bone cortical disappearance in 20, increased radiolucency of the central area in the vertebral body in 8, an irregular osteoblastic change in 5, and asymmetrical vertebral collapse in 10. An analysis of CT data revealed that intertrabecular, mildly osteolytic, and mildly osteoblastic types were more frequent in patients without any changes suggestive of bone metastases on radiographs. Radiographic findings other than the pedicle sign are useful for diagnosing bone metastases. The key to a radiographic diagnosis of spinal metastases is to pay attention to changes in the bone cortex of all vertebral components on radiographs in addition to the pedicle.

65. Contributing risk factors in patients receiving chemotherapy or immunotherapy undergoing surgical stabilization for spinal metastatic disease

<h3>BACKGROUND CONTEXT</h3> Advancements in novel, more efficacious, oncological chemo- and immunotherapies in the last decade have led to significantly prolonged survival rates in cancer patients. The vertebral column is the most common site of bony metastasis, consequently, the incidence of metastatic spine disease has increased. Much work has been done assessing postoperative complications in spine surgery secondary to radiotherapy; however, little is known on the contributing risk factors to postoperative spine complications secondary to immunotherapy. <h3>PURPOSE</h3> The purpose of this study was to assess independent risk factors for postoperative complications after surgical stabilization of spinal metastases in patients receiving either chemotherapy or immunotherapy. <h3>STUDY DESIGN/SETTING</h3> Retrospective analysis. <h3>PATIENT SAMPLE</h3> Fifty-seven patients. <h3>OUTCOME MEASURES</h3> Demographic information, tumor charecteristics and operative paramters were reviewed from the electrical medical records. Postoperative complications were assessed until 30 days after surgery. <h3>METHODS</h3> Our institution's TriNetX database was reviewed from September 2011 to September 2020. ICD-10 codes were employed to identify all patients with Stage IV metastatic disease to the vertebral column. CPT codes were utilized to capture patients in this cohort who received either chemotherapy or immunotherapy subsequently followed by surgical treatment. Patients were excluded from the study if they were younger than 18 years or received radiation therapy to the spine. Categorical outcomes were compared between patients receiving chemotherapy vs immunotherapy via Fisher's exact test analysis. Identification of risk factors for 30-day complications was achieved using a fitted model with binary logistic regression. Threshold for significance was established at p < 0.05. <h3>RESULTS</h3> Overall average age was 64.98+/-13.19 years. Average age for the chemotherapy group and the immunotherapy group was 66.64+/-12.88 and 62.52+/-13.5 (p=0.307) respectively. Among the chemotherapy group, 21 had smoked tobacco regularly, while 12 smoked regularly in the immunotherapy group (0.472). CCI (1.62+/-0.95 vs. 8.39+/-1.67, p=0.473) and ECOG (9.12+/-1.95 vs 1.7+/-1.08, p=0.604) were comparable between the two groups. Breast (9), lung (7), prostate (7) cancers were more commonly treated with chemotherapy, while immunotherapy was more commonly used to treat melanoma (10) and lung (8) cancers (p < 0.001). There was no significant difference across the groups with regards to complications. Multivariate analysis showed that smoking is an independent predictive factor for postoperative complications. <h3>CONCLUSIONS</h3> Surgical intervention, as an adjunct to immunotherapy and chemotherapy, is beneficial for sustained improvement in pain, neurologic and functional outcomes. We demonstrated, through our institution retrospective patient series, any evidence of tobacco use is a significant risk factor which may contribute to postoperative surgical complications. To our knowledge, this is the first study of its kind which assesses risk factors potentially associated with immunotherapy. Although our analysis is limited by a relatively low-powered study, future studies reviewing a larger patient cohort are needed to better conclude on possible associations between the use of immunotherapy and spine surgical stabilization in metastatic spine disease. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

61. Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4304 patients from five institutions

<h3>BACKGROUND CONTEXT</h3> Historically, spine surgeons used expected postoperative survival of three months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics and advanced radiotherapy. Recent studies have suggested that life expectancy of six weeks may be enough to achieve significant improvements in postoperative health-related quality of life. <h3>PURPOSE</h3> The purpose of this study was to develop a model capable of predicting six-week mortality in patients with spinal metastases treated with radiation or surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review was conducted at five large tertiary centers in the United States and Taiwan. <h3>PATIENT SAMPLE</h3> The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. <h3>OUTCOME MEASURES</h3> The primary outcome was six-week mortality. <h3>METHODS</h3> Five models were considered to predict six-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis and overall performance was integrated into an open access web-based application. <h3>RESULTS</h3> The most important variables for prediction of six-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. <h3>CONCLUSIONS</h3> As spinal metastasis patients with shorter life expectancy are considered for operative intervention, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

64. A novel scoring system incorporating sarcopaenia to predict postoperative survival in spinal metastasis

<h3>BACKGROUND CONTEXT</h3> As the prevalence of spinal metastasis rises, methods to predict survival will become increasingly important for clinical decision-making. Sarcopaenia may be used to predict survival in these patients. <h3>PURPOSE</h3> Our aim was to develop a prediction model for postoperative survival in patients with spinal metastasis. <h3>STUDY DESIGN/SETTING</h3> This was a retrospective cohort study. <h3>PATIENT SAMPLE</h3> Two hundred patients undergoing operative intervention for spinal metastasis were included. <h3>OUTCOME MEASURES</h3> The primary outcome measure was one-year postoperative survival. The secondary outcome measures were 3-month and 6-month postoperative survival. <h3>METHODS</h3> Clinicopathological and survivorship data were collated. Sarcopenia was defined using the L3 Psoas/Vertebral Body Ratio on cross-sectional CT. Independent predictors of survival were assessed by multiple logistic regression. Statistical analysis was conducted using GraphPad Prism statistical software. <h3>RESULTS</h3> Overall 1-year postoperative survival was 50%. L3/Psoas ratio 1.5 (OR 6.2), albumin35g/l (OR 3.0) and primary type were found to be independent predictors of 3-month, 6-month and 1-year postoperative survival on multivariable analysis. Age at surgery, ambulatory status and mode of presentation were not independent predictors of survival. Variables were used to generate a new scoring system to predict postoperative survival. This had greater correlation with postoperative survival than previous scoring systems. <h3>CONCLUSIONS</h3> This is the first model to incorporate sarcopaenia to predict survival in spinal metastasis patients and is more predictive than previous models in this cohort. This tool may be increasingly useful for informed decision-making for patients and surgeons. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4,304 patients from five institutions

BACKGROUND CONTEXTHistorically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life. PURPOSEThe purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery. STUDY DESIGN/SETTINGA retrospective review was conducted at five large tertiary centers in the United States and Taiwan. PATIENT SAMPLEThe development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. OUTCOME MEASURESThe primary outcome was 6-week mortality. METHODSFive models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application. RESULTSThe most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/. CONCLUSIONSWhile this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.