Surgery For Spinal Metastases Research Articles

Surgical site infection in spinal metastasis: incidence and risk factors

BackgroundSurgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality. ObjectiveThis study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors. Study DesignThis is a retrospective analysis of a prospectively collected data. MethodsPreoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (<90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p<.05 as significance threshold. ResultsA total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI. ConclusionThis paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

Neoadjuvant Stereotactic Body Radiation Therapy for Spine Metastases

Study Design: Retrospective study Purpose: The aim of this study was to assess the feasibility and safety of stereotactic body radiation therapy (SBRT) followed by surgery for spine metastases. Overview of Literature: SBRT has emerged as an exciting field in the management of patients with spine metastases, including those who first undergo surgery. Similarly, neoadjuvant SBRT, which means planned preoperative SBRT, should also be promising. However, there was no literature supporting this approach. Methods: Ten consecutive patients who received surgical management for spine metastases within 30 days after SBRT were reviewed. For patients with limited spine metastases, SBRT was performed first if there is no severe myelopathy. Surgery for decompression and fixation was then performed. Perioperative events were recorded and analyzed. If available, they were followed up for at least 12 months. Results: The SBRT was delivered in single fraction of 14 to 18 Gy (median: 16 Gy). Surgical decompression with fixation was performed 0 to 24 days (median: 5.5 days) after SBRT. The blood loss ranged from 100 to 1500 mL (median: 775 mL). The patients were discharged or transferred 6 to 36 days (median: 7 days) after surgery. One patient developed transient Brown-Sequard syndrome postoperatively. There was no wound complication. Five patients passed away due to progressive disease 2.3 to 13 months after surgery. There was no local recurrence and no instrument failure. Conclusions: Our experience showed that neoadjuvant SBRT followed by surgery is safe and promising for spinal metastases. The long term benefit over postoperative radiotherapy should be determined by further investigation.

Volume-Outcome Relationship in Surgical Interventions for Spinal Metastases.

Surgery for spinal metastases is challenging and carries a high risk of perioperative morbidity and mortality. Procedures with such characteristics often exhibit a volume-outcome relationship. This has not been previously characterized for spinal metastasis surgery to our knowledge. The Florida State Inpatient Database (2011 through 2014) was queried to identify patients who had undergone surgery for spinal metastases. Surgeon and hospital surgical volumes were compared with 90-day complication and readmission rates to develop procedural cut-points used to define high and low-volume providers. These were included in a multivariable logistic regression analysis that was adjusted for confounders. A separate analysis was performed to evaluate the effect of race/ethnicity and insurance status on the likelihood of receiving care from a high-volume surgeon or hospital. This study included 3,135 patients treated by 1,488 surgeons at 162 hospitals. Patients treated at low-volume hospitals had significantly higher odds of having postoperative complications (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.13, 1.91) and readmissions (OR = 1.36; 95% CI = 1.06, 1.75). Those treated by low-volume surgeons also demonstrated a higher likelihood of complications (OR = 1.40; 95% CI = 1.16, 1.69) and readmissions (OR = 1.38; 95% CI = 1.17, 1.62). The likelihood of receiving intervention from a high-volume surgeon was significantly lower for African Americans (OR = 0.55; 95% CI = 0.41, 0.75) and Hispanics (OR = 0.60; 95% CI = 0.44, 0.83). The odds of being treated at a high-volume hospital were also significantly lower for African Americans (OR = 0.58; 95% CI = 0.40, 0.84) and Hispanics (OR = 0.28; 95% CI = 0.20, 0.38). There is a clear relationship between the volume and outcomes of surgical treatment of spinal metastases, with high-volume providers demonstrating reduced complication and readmission rates. Racial and ethnic minorities appear to experience health-care segregation when it comes to surgical care for spinal metastases. Regionalization of care for these conditions may help improve access to high-volume providers and mitigate disparities in care. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessing the utility of a prognostication model to predict 1-year mortality in patients undergoing radiation therapy for spinal metastases

Background ContextPredicting survival outcomes after radiation therapy (RT) alone for metastatic disease of the spine is a challenging task that is important to guiding treatment decisions (eg, determining dose fractionation and intensity). The New England Spinal Metastasis Score (NESMS) was recently introduced and validated in independent cohorts as a tool to predict 1-year survival following surgery for spinal metastases. This metric is composed of three factors: preoperative albumin, ambulatory status, and modified Bauer score, with the total score ranging from 0 to 3. PurposeThe purpose of this study was to assess the applicability of the NESMS model to predict 1-year survival among patients treated with RT alone for spinal metastases. Study Design/SettingThis study is a retrospective analysis. Patient SampleThis sample included 290 patients who underwent conventional RT alone for spinal metastases. Outcome MeasuresPatients' NESMS (composed of ambulatory status, pretreatment serum albumin, and modified Bauer score) were assessed, as well as their 1-year overall survival rates following radiation for metastatic disease of the spine. Materials and MethodsThis study is a single-institution retrospective analysis of 290 patients treated with conventional radiation alone for spinal metastases from 2008 to 2013. The predictive value of the NESMS was assessed using multivariable logistic regression modeling, adjusted for potential confounding variables. ResultsThis analysis indicated that patients with lower NESMSs had higher rates of 1-year mortality. Multivariable analysis demonstrated a strong association between lower NESMSs and lower rates of survival. ConclusionsThe NESMS is a simple prognostic scheme that requires clinical data that are often readily available and have been validated in independent cohorts of surgical patients. This study serves to validate the utility of the NESMS composite score to predict 1-year mortality in patients treated with radiation alone for spinal metastases.

Utility of the Surgical Apgar Score for Patients Who Undergo Surgery for Spinal Metastasis.

Retrospective review of patients who underwent surgery for spinal metastasis between 2005 and 2011. To assess the utility of the surgical Apgar score (SAS) in patients who underwent surgery for spinal metastasis. Surgery for spinal metastasis can be associated with relatively high morbidity and mortality. Consequently, identifying patients at risk for major postoperative complications is important. Several studies have validated SAS for predicting 30-day complication risk. SASs were calculated and patients stratified into 5 groups: scores 0-2, 3-4, 5-6, 7-8, 9-10 points. Multivariate logistic regression assessed whether SAS was an independent predictor of major complication 30 days after surgery. Multivariate analysis of covariance assessed whether SAS was independently associated with length of stay. Ninety-seven patients with a variety of metastatic tumors were analyzed. There was no obvious trend in complication rates, or significant association between SAS and complication rate (P=0.413). Complication rates were 25.0% for SASs 0-2, 33.3% for 3-4, 18.4% for 5-6, 10.0% for 7-8, and 33.3% for 9-10 points. On multivariate analysis, SAS was not independently associated with complications; age above 65 years (odds ratio 4.19; 95% confidence interval, 1.31-52.27; P=0.028) and preoperative Karnofsky Performance Score of 10-40 (odds ratio 9.13; 95% confidence interval, 1.42-58.63; P=0.020) were associated with higher odds of complication. SASs 0-2 were an independent predictor of longer hospital stay (P=0.004). Our findings suggest that SAS is not a significant predictor of major perioperative complications after spinal metastasis surgery; preoperative functional status and age are stronger predictors. The need continues for a preoperative scoring system to reliably predict risk for perioperative complications after spinal metastasis surgery.

Prospective Cohort Study of Performance Status and Activities of Daily Living After Surgery for Spinal Metastasis.

A prospective cohort study of performance status (PS) and activities of daily living (ADL) in patients with spinal metastasis. To identify the effect of spinal surgery on PS and ADL in patients with spinal metastasis. Spinal metastasis causes severe neurological deficits, resulting in drastic loss of patients' PS and ADL. However, the effect of spine surgery on PS and ADL is not well known. Seventy patients with spinal metastasis were enrolled in this study. Forty-six patients desired and underwent spine surgery ("surgery" group) and 24 patients did not desire surgery ("nonsurgery" group). Both groups received optimal treatments, including radiation, chemotherapy, and palliative care services. Evaluation was performed at 1, 3, and 6 months after study enrollment using the Eastern Cooperative Oncology Group PS, the Barthel index (BI) for ADL, and Frankel classification for neurological status. There was no significant difference in baseline PS, the BI, or Frankel classification between the groups. The surgery group showed significant improvement in PS, maintaining grade 2 or less throughout the duration of the study, as well as in ADL, exceeding 70 points of the BI, compared with the nonsurgery group (P<0.05). Significantly improved neurological condition was also observed in the surgery group over the following 6 months. More than 95% of patients who underwent surgery improved their PS, the BI, and neurological status. Furthermore, >80% of these patients maintained improvement in PS, the BI, and neurological status for at least 6 months. In contrast, PS, the BI, and neurological status of patients in the "nonsurgery" group deteriorated throughout the study period. Spine surgery improves PS, ADL, and neurological status in patients with spinal metastasis for a minimum 6 months. This indicates that these patients can acquire an independent daily life.

Minimally Invasive Separation Surgery with Intraoperative Stereotactic Guidance: AFeasibility Study.

The treatment of spinal metastasis consists of algorithms combining surgical and radiation modalities. Recently the concept of separation surgery followed by stereotactic radiosurgery was shown to be a safe and effective treatment to achieve local tumor control. We examined a minimally invasive approach to separation surgery in a cadaveric study followed by a patient cohort with spinal metastasis using navigation to discuss our results and provide a technical note. A cadaveric study using minimally invasive access systems examined the feasibility of spinal cord decompression. Subsequently, 17 patients with spinal metastasis underwent minimally invasive separation surgery and instrumentation using navigation. All patients were at least 3/5 and pre- and post-operative CT scans were used to evaluate the decompression. Endpoints included neurologic function, operative time, estimated blood loss, duration of hospital stay, and complications. The cadaveric study demonstrated adequate decompression of the spinal cord. For the operative cases, the post-operative imaging demonstrated excellent separation for safe stereotactic radiosurgery. The mean incision length was 4.9 cm. The average operative time was 6 hours and 48 minutes, the mean length of stay was 12.8 days and the mean surgical blood loss was 458 mL. The median Spine Instability Neoplastic Score score was 10 with a range of 6-16. All patients remained or improved their neurologic baseline with excellent pain control. One patient incurred a perioperative complication. Minimally invasive separation surgery for spinal metastasis allows for circumferential decompression of the spinal cord and safe post-operative stereotactic radiosurgery. In addition, we demonstrated the efficacy of intra-operative navigation in guiding the resection.

Systematic review and meta-analysis of effectiveness of preoperative embolization in surgery for metastatic spine disease

BackgroundPreoperative embolization (PE) may decrease intraoperative blood loss (IBL) in decompressive surgery of hypervascular spinal metastases. However, no consensus has been found in other metastases and no meta-analysis which reviewed...

Incidence and risk factors for preoperative deep venous thrombosis in 314 consecutive patients undergoing surgery for spinal metastasis.

OBJECTIVE The authors of this study aimed to identify the incidence of and risk factors for preoperative deep venous thrombosis (DVT) in patients undergoing surgical treatment for spinal metastases. METHODS Univariate analysis of patient age, sex, ethnicity, laboratory values, comorbidities, preoperative ambulatory status, histopathological classification, spinal level, and surgical details was performed. Factors significantly associated with DVT univariately were entered into a multivariate logistic regression model. RESULTS The authors identified 314 patients, of whom 232 (73.9%) were screened preoperatively for a DVT. Of those screened, 22 (9.48%) were diagnosed with a DVT. The screened patients were older (median 62 vs 55 years, p = 0.0008), but otherwise similar in baseline characteristics. Nonambulatory status, previous history of DVT, lower partial thromboplastin time, and lower hemoglobin level were statistically significant and independent factors associated with positive results of screening for a DVT. Results of screening were positive in only 6.4% of ambulatory patients in contrast to 24.4% of nonambulatory patients, yielding an odds ratio of 4.73 (95% CI 1.88-11.90). All of the patients who had positive screening results underwent preoperative placement of an inferior vena cava filter. CONCLUSIONS Patients requiring surgery for spinal metastases represent a population with unique risks for venous thromboembolism. This study showed a 9.48% incidence of DVT in patients screened preoperatively. The highest rates of preoperative DVT were identified in nonambulatory patients, who were found to have a 4-fold increase in the likelihood of harboring a DVT. Understanding the preoperative thrombotic status may provide an opportunity for early intervention and risk stratification in this critically ill population.

Spine Stereotactic Body Radiotherapy: Indications, Outcomes, and Points of Caution.

Study Design:A broad narrative review.Objectives:The objective of this article is to provide a technical review of spine stereotactic body radiotherapy (SBRT) planning and delivery, indications for treatment, outcomes, complications, and the challenges of response assessment. The surgical approach to spinal metastases is discussed with an overview of emerging minimally invasive techniques.Methods:A comprehensive review of the literature was conducted on the techniques, outcomes, and developments in SBRT and surgery for spinal metastases.Results:The optimal management of patients with spinal metastases is complex and requires multidisciplinary assessment from an oncologic team that is familiar with the shifting paradigm as a consequence of evolving techniques in surgery and stereotactic radiation, as well as new developments in systemic agents. The Spinal Instability Neoplastic Score and the epidural spinal cord compression (Bilsky) grading system are useful tools that facilitate communication among oncologic team members and can direct management by providing a baseline assessment of risks prior to therapy. The combined multimodality approach with “separation surgery” followed by postoperative spine SBRT achieves thecal sac decompression, improves tumor control, and avoids complications that may be associated with more extensive surgery.Conclusion:Spine SBRT is a highly effective treatment that is capable of delivering ablative doses to the target while sparing the critical organs-at-risk, chiefly the critical neural tissues, within a short and manageable schedule. At the same time, surgery occupies an important role in select patients, particularly with the expanding availability and expertise in minimally invasive techniques. With rapid adoption of spine SBRT in centers outside of the academic setting, it is imperative for the practicing oncologist to understand the relevance and application of these evolving concepts.

Perioperative Complications of Spinal Metastases Surgery: Erratum

Perioperative Complications of Spinal Metastases Surgery: Erratum

Surgical intervention for vertebral metastases may benefit lung cancer patients no less than other patients: a retrospective study

BackgroundSpinal metastasis is considered to have a worse prognosis in lung cancer than in other cancers, but recent clinical studies report improved overall survival of lung cancer. We compared the postoperative prognoses of vertebral metastatic tumors from lung with other types of cancer.MethodsFrom 2011 to 2015, 31 Japanese patients (mean age 73 years, range 55–88 years; 19 males, 12 females) underwent surgery for spinal metastasis at our center. We observed patients retrospectively in March 2016, dividing them into groups by cancer type: lung (LK group, n = 10); prostate, breast, or thyroid (PB group, n = 12); and other (OT group, n = 9). We compared survival and revised Tokuhashi score, which provides a basis for choosing a treatment course. Neurologic status was graded before and after surgery using the Frankel system.ResultsMean follow-up was 16.5 months (range 1–62 months). Only seven of 31 patients (22.6%) were alive at final follow-up. Frankel grade significantly improved postoperatively only in the LK (P = 0.01) and PB (P = 0.048) groups. Revised Tokuhashi score differed across groups (P < 0.0001), and was significantly lower in the LK group than in the PB group (P = 0.00) and OT group (P = 0.02). Postoperative survival was significantly shorter in the LK group than in the PB group (P = 0.01) but did not differ between the LK and OT groups.ConclusionsThe revised Tokuhashi score may underestimate the survival of lung cancer patients, who may derive the same benefit from surgical intervention as those with vertebral metastasis from other cancer types.

Radical surgery consisting of en bloc corpectomy in recurrence after palliative surgery for spinal metastasis.

Introduction We often experience recurrence of spinal metastases after palliative surgery, even with radiotherapy. We examined the clinical outcome of radical surgery containing en bloc corpectomy for patients with recurrent spinal metastasis. Methods Seven patients underwent en bloc corpectomy for recurrent spinal metastases. We assessed the prognosis scores (Tomita, Tokuhashi), pre- and postoperative Frankel scale scores, operation time, intraoperative blood loss, and perioperative complications. Results The preoperative estimated prognosis was less than six months (two patients), six months to one year (two patients), and over one year (three patients), according to Tokuhashi score. Major perioperative complications were dura mater injury and pleural injury. Neurological improvement was seen in four patients. All patients were ambulatory at discharge and lived longer than the preoperatively estimated life expectancy (range: seven months to four years). Conclusions Radical surgery consisting of en bloc corpectomy may be a therapeutic choice for patients with recurrent spinal metastases.

Management and cost of surgical site infection in patients undergoing surgery for spinal metastasis

Surgical site infection (SSI) is a serious potential complication of spinal surgery. SSI may impact significantly on inpatient hospitalization and the costs associated with extra care. To investigate the management of patients experiencing SSI following surgery for spinal metastatic tumours, and to estimate the costs associated with SSI in this context. Patients experiencing SSI following spinal tumour surgery at a large spinal surgery centre between January 2009 and December 2012 were identified. Existing case notes were reviewed and patient and procedural data, details of the infection, and treatment interventions were recorded. A bottom-up approach to calculating costs associated with infection was used for patients experiencing SSI and compared with a quasi-random sample of similar patients without SSI. The mean cost of treating patients with SSI was significantly greater than costs associated with those without SSI (P=0.019). Mean cost of inpatient hospital stay was 60% higher in patients with SSI compared to those without SSI (P=0.004). Inpatient hospital stay alone accounted for 59% of total costs. Return to theatre was the second most costly intervention overall, accounting for 38% of costs, and was the most expensive single intervention involved in the treatment of SSI. SSI significantly increases healthcare costs for patients undergoing surgery for spinal metastasis, with prolonged inpatient hospitalization and return to theatre for wound management being major contributors. The actual total cost to society derived from SSI in this patient group is likely to be far beyond just the direct costs to healthcare providers.

Place de la chirurgie dans la prise en charge des métastases vertébrales. Revue générale

The spine is the most common site of skeletal metastases. Treatment decisions for patients with spinal metastases can be challenging and greatly depend on survival prognosis. Surgery remains a valuable weapon in the therapeutic arsenal. A review of the literature describing the role of surgery, the various surgical approaches and the prognostic scores available for the management of spinal metastases was performed and summarized. Surgery for spinal metastases has 3 main objectives: management of pain, achievement of mechanical stability and preservation or restoration of neurological function. A variety of surgical approaches are available and depend on location of tumor, presence of instability, neurological status, oncologic prognosis, general performance status and subsequent treatment measures. The goal of any therapeutic course for a spinal metastasis is the best oncologic and functional result with the least aggressive treatment. Novelty surgical and adjunctive measures allow a multidisciplinary approach to the metastatic spine.

Characteristics of Patients Who Survived < 3 Months or > 2 Years After Surgery for Spinal Metastases: Can We Avoid Inappropriate Patient Selection?

Survival after metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with pathologic spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve quality of life. Surgery is generally considered to be inappropriate if anticipated survival is < 3 months. The aim of this international multicenter study was to analyze data from patients who died within 3 months or 2 years after surgery, to identify preoperative factors associated with poor or good survival, and to avoid inappropriate selection of patients for surgery in the future. A total of 1,266 patients underwent surgery for impending pathologic fractures and/or neurologic deficits and were prospectively observed. Data collected included tumor characteristics, preoperative fitness (American Society of Anesthesiologists advisory [ASA]), neurologic status (Frankel scale), performance (Karnofsky performance score [KPS]), and quality of life (EuroQol five-dimensions questionnaire [EQ-5D]). Outcomes were survival at 3 months and 2 years postsurgery. Univariable and multivariable logistic regression analyses were used to find preoperative factors associated with short-term and long-term survival. In univariable analysis, age, emergency surgery, KPS, EQ-5D, ASA, Frankel, and Tokuhashi/Tomita scores were significantly associated with short survival. In multivariable analysis, KPS and age were significantly associated with short survival (odds ratio [OR], 1.36; 95% CI, 1.15 to 1.62; and OR, 1.14; 95% CI, 1.02 to 1.27, respectively). Associated with longer survival in univariable analysis were age, number of levels included in surgery, KPS, EQ-5D, Frankel, and Tokuhashi/Tomita scores. In multivariable analysis, the number of levels included in surgery (OR, 1.21; 95% CI, 1.06 to 1.38) and primary tumor type were significantly associated with longer survival. Poor performance status at presentation is the strongest indicator of poor short-term survival, whereas low disease load and favorable tumor histology are associated with longer-term survival.

Survival of patients undergoing surgery for metastatic spinal tumours and the impact of surgical site infection

Patients with metastatic spinal tumours have a limited prognosis. Surgical complications that may result in prolonged hospitalization or readmission are highly undesirable. Surgical site infection (SSI) is one such complication, which can, in extreme cases, lead to death. To assess the impact of SSI on patient survival after surgery for spinal metastases. Demographic, operative, and survival data were collected on 152 patients undergoing surgery for spinal metastasis at a large UK tertiary referral centre. American Society of Anesthesiologists (ASA) grade and the Revised Tokuhashi Score (RTS) were determined as measures of health status and prognosis, respectively, at baseline. A semi-parametric Cox proportional hazards survival analysis was used to assess the relationships between covariates and survival. Seventeen patients (11.2%) experienced SSI. Overall, median survival time from operation was 262 days (95% confidence interval: 190-334 days) and 12-month survival was 42.1%. RTS (hazard ratio: 0.82; 95% confidence interval: 0.76-0.89; P<0.001) and ASA grade (1.37; 1.03-1.82; P=0.028) were significantly associated with survival, with better survival found in patients with higher RTS and lower ASA scores. Infection status was of substantive importance, with better survival in those without SSI (P=0.075). Twelve-month survival in patients undergoing surgery for spinal metastasis is ∼42%. RTS and ASA scores may be used as indicators of patient survival either in combination or individually. Whereas SSI has some negative impact on survival, a larger study sample would be needed to confirm whether this is statistically significant.

The Influence of Histological Subtype in Predicting Survival of Lung Cancer Patients with Spinal Metastases

Introduction Lung cancer is one of the most common primaries responsible for spinal metastases. Recent advancements in systemic therapies for lung cancer have significantly improved the survival of patients with certain histological subtypes. Existing prognostic scoring systems have little to no prognostic value in lung cancer spinal metastases, and this may be due to the lack of consideration of lung cancer histology in their algorithms. Since prognostication plays a key role in the decision for operative management of spinal metastases, this study aims to analyze survival of lung cancer patients with spinal metastases according to different histological subtypes, to provide some guidance in making more informed surgical management decisions, better complementing recent medical oncologic advancements. Materials and Methods All patients with histologically confirmed lung cancer treated for spinal metastases at our institution between May 2001 and April 2012 were retrospectively reviewed. The primary outcome measure was survival from the time of diagnosis. Survival data was obtained from the National Registry of Diseases Office. Patient demographic variables, lung cancer histology and various modalities of oncologic treatment were evaluated. Univariate and multivariate cox regression analyses of were performed using Stata v.12. Statistical significance was defined as p &lt; 0.05. Results Out of a total of 180 patients, 51 were treated surgically. The overall median survival time was 4.8 months, (range: 0.1–111.1 months). When subdivided according to histology, patients with non-small cell lung cancer (NSCLC) had a median survival of 5.2 (range: 0.1–111.1) months while patients with small cell lung cancer had a median survival of 2.4 (range: 0.1–11.9) months. Female gender ( p = 0.049), chinese ethnicity ( p = 0.040), NSCLC ( p &lt; 0.001), treatment with epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) therapy ( p &lt; 0.001), treatment with platinum doublet chemotherapy ( p &lt; 0.001), and local radiotherapy ( p = 0.070) for spinal metastases were all significant good prognostic factors upon both univariate and multivariate analysis. Surgery for spinal metastases itself did not significantly improve survival ( p = 0.147). Conclusions Female gender, chinese ethnicity, NSCLC, treatment with EGFR TKI therapy, treatment with platinum doublet chemotherapy, and local radiotherapy for spinal metastases are all independent favorable prognostic factors for patients with lung cancers spinal metastases. Profiling patients according to these factors should help guide decisions for surgical management of spinal metastases given that prognostic scoring systems are currently not predictive in this patient group.

Characteristics of Patients who Survived Less than Three Months or Greater than Two Years after Surgery for Spinal Metastases: Can We Avoid Inappropriate Patient Selection?

Introduction The survival of patients with metastatic cancer has improved at the cost of increased presentation with metastatic spinal disease. For patients with (impending) pathological spinal fractures and/or spinal cord compression, surgical intervention may relieve pain and improve mobility and quality of life. It is generally accepted that surgery is inappropriate if anticipated survival is less than three months, and survival greater than two years is uncommon. The aim of this international multicenter prospective cohort study was to analyze data from surgical patients who died within three months, or after two years from surgery, to identify any preoperative factors which might be associated particularly with poor survival, to avoid inappropriate selection of patients for surgery in the future. Patients and Methods A total of 1266 patients were treated surgically for (impending) pathological fractures and/or neurological deficits and were prospectively followed. Data collected included tumor characteristics, preoperative fitness (ASA), neurological status (ASIA), performance status (KPS), and quality of life (EQ-5D). Primary outcomes were survival at three months and two years postsurgery. Univariate and multivariate logistic regression analysis were used to find preoperative factors associated with short- and long term survival. Results In univariate analysis age, emergency surgery, KPS, EQ-5D, ASA, ASIA, and Tokuhashi/Tomita scores were all significantly associated with short survival. In multivariate analysis, however, only KPS was significantly associated with short survival (OR 1.40; CI 1.18–1.67). Associated with longer survival in univariate analysis were age, number of spinal levels included in the surgery, KPS, EQ-5D, ASIA, and Tokuhashi/Tomita scores. In multivariate analysis, only the number of affected spinal levels included in the surgery was significantly associated with longer survival (OR 1.21; CI 1.03–1.41). Conclusion Poor performance status at presentation is the strongest indicator of poor survival (less than 3 months), whereas a low disease load with fewer involved spinal levels is strongly associated with longer term survival.

Are allogeneic blood transfusions associated with decreased survival after surgical treatment for spinal metastases?

Background ContextPerioperative allogeneic blood transfusions have been associated with decreased survival after surgical resection of primary and metastatic cancer. Studies investigating this association for patients undergoing resection of bone metastases are scarce and controversial. PurposeWe assessed (1) whether exposure to perioperative allogeneic blood transfusions was associated with decreased survival after surgery for spinal metastases and (2) if there was a dose-response relationship per unit of blood transfused. Additionally, we explored the risk factors associated with survival after surgery for spinal metastases. Study Design/SettingThis is a retrospective cohort study from two university medical centers. Patient SampleThere were 649 patients who had operative treatment for metastatic disease of the spine between 2002 and 2014. Patients with lymphoma or multiple myeloma were also included. We excluded patients with a revision procedure, kyphoplasty, vertebroplasty, and radiosurgery alone. Outcome MeasuresThe outcome measure was survival after surgery. The date of death was obtained from the Social Security Death Index and medical charts. MethodsBlood transfusions within 7 days before and 7 days after surgery were considered perioperative. A multivariate Cox proportional hazard model was used to assess the relationship between allogeneic blood transfusion as exposure versus non-exposure, and subsequently as continuous value; we accounted for clinical, laboratory, and treatment factors. ResultsFour hundred fifty-three (70%) patients received perioperative blood transfusions, and the median number of units transfused was 3 (interquartile range: 2–6). Exposure to perioperative blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.80–1.31; p=.841). Neither did we find a dose-response relationship (HR: 1.01; 95% CI: 0.98–1.04; p=.420). Other factors associated with worse survival were older age, more severe comorbidity status, lower preoperativehemoglobin level, higher white blood cell count, higher calcium level, primary tumor type, previous systemic therapy, poor performance status, presence of lung, liver, or brain metastasis, and surgical approach. ConclusionsPerioperative allogeneic blood transfusions were not associated with decreased survival after surgery for spinal metastases. More liberal transfusion policies might be warranted for patients undergoing surgery for spinal metastasis, although careful consideration is needed as other complications may occur.