Unstable Spinal Metastases Research Articles

PH-0521: Paravertebral Muscle Training in Patients with Unstable Spinal Metastases

PH-0521: Paravertebral Muscle Training in Patients with Unstable Spinal Metastases

Safe And Feasible Exercises For The Paravertebral Muscles In Cancer Patients With Unstable Spinal Metastases

PURPOSE: Previous work showed that cancer patients with spinal metastases classified as stable (i.e. with low fracture risk) benefit from isometric exercises for the paravertebral muscles concomitant to palliative radiotherapy in terms of bone density and pain. In this exploratory randomized controlled trial we investigated whether paravertebral muscle training is safe and feasible also in patients with spinal metastases classified as unstable (i.e. with high fracture risk). METHODS: Sixty cancer patients with unstable spinal metastases (Taneichi score ≥D) were randomized to an intervention group (INT, n=27 starters) or a control group (CON, n=29 starters). INT received 15 min of 1:1-supervised isometric exercises (“all fours”, “plank”, “swimmer”, and a standing exercise with an elastic band) daily on 10±2 days of radiotherapy and continued home-based on 3 days/week for 3 months. CON received muscle relaxation. Adverse events and adherence (primary endpoints), strength, pain and quality of life (secondary endpoints) were assessed. RESULTS: In 41% of patients, exercises were modified because of pain or immobility. There were no training-related adverse events. During radiotherapy, 67% of patients in INT and 55% of patients in CON attended ≥80% of the planned training sessions. During home-based training, 64% of patients in INT performed ≥80% of the planned training sessions. Plank position holding time (strength) increased by 24±28 s in INT and dropped by 2±34 s in CON by the end of radiotherapy (p=0.01). There were no differences between groups for pain or quality of life (p>0.05). CONCLUSIONS: The described or individually modified isometric exercises for the paravertebral muscles are safe and in about 2/3 of cancer patients with unstable spinal metastases feasible when introduced 1:1 and continued home-based. To investigate potential benefits, larger studies powered for patient reported outcomes and clinical endpoints are needed.

Paravertebral Muscle Training in Patients with Unstable Spinal Metastases Receiving Palliative Radiotherapy: An Exploratory Randomized Feasibility Trial.

Background: Isometric paravertebral muscle training (IPMT) may improve mobility, pain, and quality of life (QOL) in cancer patients with spinal metastases. However, this regimen remains unproven in patients with unstable spinal metastases (USM), a population at high risk for clinical exacerbation with such interventions. Thus, we conducted this exploratory, non-blinded, randomized controlled trial (NCT02847754) to evaluate the safety/feasibility of IPMT and secondarily assess pain, bone density, pathologic fracture rate, and QOL. Methods: All patients had histologically/radiologically confirmed USM (per Taneichi score) and underwent non-operative management with 5–10 fractions of palliative radiotherapy (RT). Randomization (1:1) groups were IPMT (intervention, INT) or muscle relaxation (control, CON); both lasted 15 min/day and started concurrently with radiotherapy. The primary endpoint was feasibility (completion of training programs three months post-RT). Secondary endpoints were pain response (Visual Analog Scale) and opioid consumption, bone density and pathologic fracture rate, and QOL (European Organization for Research and Treatment of Cancer, EORTC questionnaires). Results: Sixty patients were randomized and 56 received protocol therapy. Mean survival in both groups was 4.4 months. There were no adverse events with either training regimen. Altogether, ≥80% of the planned sessions were completed by 55% (n = 16/29) in CON and 67% (n = 18/27) in INT. Regarding the post-radiotherapy home-based training, ≥80% of planned sessions were completed by 64% (n = 9/14) of the INT cohort. There were no differences in pain scores, opioid consumption, or bone density between arms (p > 0.05 for all). No difference was observed between groups regarding new pathological fractures (INT: n = 1 vs. CON: n = 3) after three months (p = 0.419). There were no QOL differences between arms (all parameters p > 0.05). Conclusions: IPMT is potentially feasible for high-risk USM patients. Future trials adequately powered for relevant endpoints are thus recommended.

EP-1439: Percutaneous pedicle screw fixation for the treatment of unstable spinal metastases

EP-1439: Percutaneous pedicle screw fixation for the treatment of unstable spinal metastases

The Effect of Introducing the Spinal Instability Neoplastic Score in Routine Clinical Practice for Patients With Spinal Metastases.

Stable spinal metastases are effectively treated with radiotherapy, whereas unstable spinal metastases often need surgical fixation followed by radiotherapy for local control. The Spinal Instability Neoplastic Score (SINS) was developed as a tool to assess spinal neoplastic related instability with the goal of helping to guide referrals among oncology specialists. We compare the average degree of spinal instability between patients with spinal metastases referred for surgery or for radiotherapy and evaluate whether this difference changed after introduction of the SINS in clinical practice. All patients with spinal metastases treated with palliative surgery or radiotherapy in the period 2009-2013 were identified in two spine centers. For all patients, the SINS was scored on pretreatment imaging. The SINS before and after introduction of the SINS in 2011 were compared within the surgical and radiotherapy group. Furthermore, the overall SINS was compared between the two groups. The overall SINS was significantly higher in the surgical group, with a mean SINS of 10.7 (median 11) versus 7.2 (median 8) for the radiotherapy group. The mean SINS decreased significantly for both groups after introduction of the SINS in clinical practice from 11.2 to 10.3 in the surgical group and from 8.4 to 7.2 in the radiotherapy group. The SINS differed significantly between patients treated with surgery or radiotherapy. The introduction of SINS led to a decrease in SINS score for both groups, suggesting that using SINS in metastatic spinal disease increases awareness for instability and may subsequently result in earlier referrals for surgical intervention. Spinal metastases can present with varying degrees of mechanical instability. Because unstable spinal metastases may respond insufficiently to palliative radiotherapy and can lead to loss of ambulation, timely detection and appropriate referral are important. The Spinal Instability Neoplastic Score (SINS) may help physicians caring for patients with metastasized disease to identify spinal instability before the onset of neurological deficits. In this study, it was shown that the introduction of SINS in routine practice led to a decrease in spinal instability in radiotherapy and surgical cohorts. The use of SINS may increase awareness of instability and subsequently result in earlier referrals.

Quality of life, fatigue and local response of patients with unstable spinal bone metastases under radiation therapy - a prospective trial

BackgroundTo evaluate the local response according to stability after radiotherapy (RT) with a special focus on quality-of-life (QoL), fatigue, pain and emotional distress in patients with unstable spinal bone metastases.MethodsIn this prospective trial, 30 patients were treated from September 2011 until March 2013. The stability of osteolytic metastases in the thoracic and lumbar spine was evaluated on the basis of the Taneichi-score after three and six months. EORTC QLQ-BM22, EORTC QLQ-FA13, and QSC-R10 were assessed at baseline, and three months after RT.ResultsAfter 3 months, 25% (n = 6) and after 6 months 33.3% (n = 8) were classified as stable. QoL, fatigue, and emotional distress showed no difference over the course. The pain response 3 months after RT showed a significant difference (p < 0.001). Pathological fractures occurred in 8.3% of the patients (n = 2) within six months following RT.ConclusionsOur trial demonstrated that RT can improve stability in one third of patients over a 6-months period with unstable spinal metastases. Importantly, for these patients pain relief was detected but RT had no impact on QoL, fatigue, and emotional distress.Trial registrationClinical trial identifier NCT01409720.