Patient-Reported and Clinical Outcomes of Surgically Treated Patients With Symptomatic Spinal Metastases: Results From Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO), a Prospective, Multi-Institutional and International Study.

BACKGROUND AND OBJECTIVES: The palliative impact of spine surgery for metastatic disease is evolving with improvements in surgical technique and multidisciplinary cancer care. The goal of this study was to prospectively evaluate long-term clinical outcomes including health-related quality-of-life (HRQOL) measures, using spine cancer-specific patient-reported-outcome (PRO) measures, in patients with symptomatic spinal metastases who underwent surgical management. METHODS: The Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO, ClinicalTrials.gov identifier: NCT01825161) trial is a prospective-observational cohort study that included 10 specialist centers in North America and Europe. Patients aged 18 to 75 years who underwent surgery for spinal metastases were included. Prospective assessments included both spine tumor-specific and generic PRO tools which were collected for a minimum of 2 years post-treatment or until death. RESULTS: Two hundred and eighty patients (51.8% female, mean age 57.9 years) were included. At presentation, the mean Charlson Comorbidity Index was 6.0, 35.7% had neurological deficits as defined by the American Spinal Cord Injury Association scores, 47.2% had high-grade epidural spinal cord compression (2-3), and 89.6% had impending or frank instability as measured by a Spinal Instability Neoplastic Score of ≥7. The most common primary tumor sites were breast (20.2%), lung (18.8%), kidney (16.2%), and prostate (6.5%). The median overall survival postsurgery was 501 days, and the 2-year progression-free-survival rate was 38.4%. Compared with baseline, significant and durable improvements in HRQOL were observed at the 6-week, 12-week, 26-week, 1-year, and 2-year follow-up assessments from a battery of PRO questionnaires including the spine cancer-specific, validated, Spine Oncology Study Group Outcomes Questionnaire v2.0, the Short Form 36 version 2, EuroQol-5 Dimension (3L), and pain numerical rating scale score. CONCLUSION: Multi-institutional, prospective-outcomes data confirm that surgical decompression and/or stabilization provides meaningful and durable improvements in multiple HRQOL domains, including spine-specific outcomes based on the Spine Oncology Study Group Outcomes Questionnaire v2.0, for patients with metastatic spine disease.

Gender and Sex Differences in Health-related Quality of Life, Clinical Outcomes and Survival after Treatment of Metastatic Spine Disease.

STUDY DESIGN: Retrospective review of prospective, multicenter and international cohort study. OBJECTIVE: To describe the effect of gender on HRQoL, clinical outcomes and survival for patients with spinal metastases treated with either surgery and/or radiation. SUMMARY OF BACKGROUND DATA: Gender differences in health-related outcomes are demonstrated in numerous studies, with women experiencing worse outcomes and receiving lower standards of care than men, however, the influence that gender has on low health-related quality of life (HRQoL) and clinical outcomes after spine surgery remains unclear. METHODS: Patient demographic data, overall survival, treatment details, perioperative complications, and HRQoL measures including EQ-5D, pain NRS, the short form 36 version 2 (SF-36v2) and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) were reviewed. Patients were stratified by sex, and a separate sensitivity analysis that excluded gender-specific cancers (i.e., breast, prostate, etc.) was performed. RESULTS: The study cohort included 207 female and 183 male patients, with age, smoking status, and site of primary cancer being significantly different between the two cohorts (P<0.001). Both males and females experienced significantly improved SOSGOQ2.0, EQ-5D, and pain NRS scores at all study time points from baseline (P<0.001). Upon sensitivity analysis, (gender-specific cancers removed from analysis), the significant improvement in SOSGOQ physical, mental, and social subdomains and on SF-36 domains disappeared for females. Males experienced higher rates of postoperative complications. Kaplan-Meier survival analysis of both the overall and sensitivity analysis cohorts showed females lived longer than males after treatment (P=0.001 and 0.043, respectively). CONCLUSION: Both males and females experienced significantly improved HRQoL scores after treatment, but females demonstrated longer survival and a lower complication rate. This study suggests that gender may be a prognostic factor in survival and clinical outcomes for patients undergoing treatment for spine metastases and should be taken into consideration when counseling patients accordingly.

Diagnostic Approach and Differences between Spinal Infections and Tumors.

STUDY DESIGN: A systematic review of the literature about differential diagnosis between spine infection and bone tumors of the spine. BACKGROUND AND PURPOSE: The differential diagnosis between spine infection and bone tumors of the spine can be misled by the prevalence of one of the conditions over the other in different areas of the world. A review of the existing literature on suggestive or even pathognomonic imaging aspects of both can be very useful for correctly orientating the diagnosis and deciding the most appropriate area for biopsy. The purpose of our study is to identify which imaging technique is the most reliable to suggest the diagnosis between spine infection and spine bone tumor. METHODS: A primary search on Medline through PubMed distribution was made. We identified five main groups: tuberculous, atypical spinal tuberculosis, pyogenic spondylitis, and neoplastic (primitive and metastatic). For each group, we evaluated the commonest localization, characteristics at CT, CT perfusion, MRI, MRI with Gadolinium, MRI diffusion (DWI) and, in the end, the main features for each group. RESULTS: A total of 602 studies were identified through the database search and a screening by titles and abstracts was performed. After applying inclusion and exclusion criteria, 34 articles were excluded and a total of 22 full-text articles were assessed for eligibility. For each article, the role of CT-scan, CT-perfusion, MRI, MRI with Gadolinium and MRI diffusion (DWI) in distinguishing the most reliable features to suggest the diagnosis of spine infection versus bone tumor/metastasis was collected. CONCLUSION: Definitive differential diagnosis between infection and tumor requires biopsy and culture. The sensitivity and specificity of percutaneous biopsy are 72% and 94%, respectively. Imaging studies can be added to address the diagnosis, but a multidisciplinary discussion with radiologists and nuclear medicine specialists is mandatory.

Outcomes of Surgical Treatment for Extradural Benign Primary Spinal Tumors in Patients Younger than 25 Years: An Ambispective International Multicenter Study.

Extradural primary spinal tumors were retrospectively analyzed from a prospective database of 1495 cases. All subjects with benign primary tumors under the age of 25 years, who were enrolled between 1990 and 2012 (Median FU was 2.4 years), were identified. Patient- and case-related characteristics were collected and statistically analyzed. Results: 161 patients (66f;95m; age 17.0 ± 4.7 years at time of diagnosis) were identified. The most common tumors were osteoblastomas n = 53 (32.9%), osteoid osteomas n = 45 (28.0%), and aneurysmal bone cysts n = 32 (19.9%). The tumor grade, according to the Enneking Classification S1/S2/S3, was 14/73/74 (8.7/45.3/46.0%), respectively. Tumor-related pain was present in 156 (96.9%) patients. Diagnosis was achieved by biopsies in 2/3 of the cases. Spinal fixation was used in >50% of the cases. Resection was Enneking appropriate in n = 100 (62.1%) of cases. Local recurrence occurred in 21 (13.1%) patients. Two patients died within a 10-year follow-up period. Conclusion: This is one of the largest international multicenter cohorts of young patients surgically treated for benign spinal tumors. The heterogenic young patient cohort presented at a mid-term follow-up without a correlation between the grade of aggressiveness in resection and local recurrence rates. Further prospective data are required to identify prognostic factors that determine oncological and functional outcomes for young patients suffering from these rare tumors.

Extradural Primary Malignant Spinal Tumors in a Population Younger than 25 Years: An Ambispective International Multicenter Study on Onco-Surgical Outcomes.

Extradural malignant primary spinal tumors are rare and outcome data, especially for younger patients, is limited. In a worldwide (11 centers) study (Predictors of Mortality and Morbidity in the Surgical Management of Primary Tumors of the Spine study; ClinicalTrials.gov Identifier NCT01643174) by the AO Spine Knowledge Forum Tumor, patients surgically treated for primary tumors of the spine between 1992 and 2012, were retrospectively analyzed from a prospective database of their medical history. Medical history, tumor characteristics, diagnostics, treatments, cross-sectional survival, and local recurrences were analyzed. Sixty-eight cases (32 f; 36 m), at an average age of 18.6 ± 4.7 years at the time of diagnosis, were identified (median follow-up 2.9 years). The most common entities were Ewing's sarcoma (42.6%). Of the patients, 28% had undergone previous spine tumor surgery in another center (84% with intralesional margins). Resection was considered "Enneking appropriate" (EA) in 47.8% of the cases. Of the patients, 77.9% underwent chemotherapy and 50% radiotherapy. A local recurrence occurred in 36.4%. Over a third of patients died within a 10-year follow-up period. Kaplan-Meier-analysis demonstrated statistically significant overall survival (p = 0.007) and local recurrence rates (p = 0.042) for tumors treated with EA surgery versus Enneking inappropriate surgery. Aggressive resection of extradural primary malignant spinal tumors combined with adjuvant therapy reveals low local recurrence rates and better outcomes overall in younger patients.

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

STUDY DESIGN: International multicenter prospective observational cohort study on patients undergoing radiation +/- surgical intervention for the treatment of symptomatic spinal metastases. OBJECTIVES: To investigate the association between the total Spinal Instability Neoplastic Score (SINS), individual SINS components and PROs. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

En-bloc resection of a chordoma in L3 by a combined open posterior and less invasive retroperitoneal approach: technical description and case report.

INTRODUCTION: To fulfill oncological criteria, extensive open anterior and posterior approaches are usually performed in the lumbar spine to obtain an appropriate en-bloc spondylectomy. It is commonly accepted that the price of a tumor-free margin includes such extensive incisions and soft-tissue damage, with consequent relevant blood loss and possible postoperative complications as delayed wound healing. In this article, a case of chordoma in L3 is presented, submitted to an oncologically appropriate en-bloc resection performed by an open posterior approach combined with a mini-retroperitoneal approach. The successful oncologic procedure was combined with a short and uneventful postoperative course. MATERIALS AND METHODS: The authors present the surgical technique and the possible challenges of minimally invasive anterior oncologic surgery as a contribution to a limited literature. RESULTS: Up to date, palliative care of single metastases has been the main setting in which anterior, minimally invasive surgery has been performed in the lumbar spine. The authors explained how, in selected cases, this approach can be performed in combination with an open posterior access for an oncologically appropriate treatment of a primary malignant tumor. CONCLUSION: Anterior, minimally invasive surgery can have a role in selected patients with primary malignant tumors of the lumbar spine. The surgical team should have extensive training both in oncologic and minimally invasive surgery.

En bloc resection of huge primary tumors with epidural involvement in the mobile spine using the "rotation-reversion" technique: Feasibility, safety, and clinical outcome of 11 cases.

Background: En bloc resection of spinal tumors provides better local control and survival outcomes than intralesional resection. Safe margins during en bloc resection of primary spinal tumors with epidural involvement are required for improved outcomes. The present study describes a "rotation-reversion" technique that has been used for en bloc resection of huge primary tumors in the mobile spine with epidural involvement and reported the clinical outcomes in these patients. Methods: All patients with primary spinal tumors who were treated with the rotation-reversion technique at our institution between 2015 and 2021 were evaluated retrospectively. Of the patients identified, those with both huge extraosseous soft-tissue masses and epidural involvement were selected for a case review. Clinical and radiological characteristics, pathologic findings, operative procedures, complications, and oncological and functional outcomes of these patients were reviewed. Results: Of the 86 patients identified with primary spinal tumors who underwent en bloc resection using the rotation-reversion technique between 2015 and 2021, 11 had huge extraosseous soft-tissue masses with epidural involvement in the mobile spine. The average maximum size of these 11 tumors was 8.1 × 7.5 × 9.7 cm. Median follow-up time was 28.1 months, mean operation time was 849.1 min (range 465-1,340 min), and mean blood loss was 6,972.7 ml (range 2,500-17,700 ml), with 10 (91%) of the 11 patients experiencing perioperative complications. The negative margin rate was 91%, with only one patient (9%) experiencing local recurrence. Ten patients were able to walk normally or with a crutch at the last follow-up, whereas one was completely paralyzed preoperatively. Conclusion: The rotation-reversion technique is an effective procedure for the en bloc resection of huge primary spinal tumors, with the extension of invasion in selected patients including not only the vertebral body but also the pedicle and part of the posterior arch.

Rapidly destructive osteoarthritis of the spine: lessons learned from the first reported case.

BACKGROUND: Rapidly Destructive Osteoarthritis (RDOA) has been described for the hip and shoulder joints and is characterized by a quickly developing bone edema followed by extensive remodeling and joint destruction. Confronted with a similarly evolving case of endplate edema and destruction of the disk space, we offer the first described case of spinal RDOA and illustrate the challenges it presented, along with the strategies we put in place to overcome them. CASE PRESENTATION: We present a case of spinal RDOA that, also due to the delay in the diagnoses, underwent multiple revisions for implant failure with consequent coronal and sagittal imbalance. A 37-years-old, otherwise healthy female presented with atraumatic low back pain: after initial conservative treatment, subsequent imaging showed rapidly progressive endplate erosion and a scoliotic deformity. After surgical treatment, the patient underwent numerous revisions for pseudoarthrosis, coronal and sagittal imbalance and junctional failure despite initially showing a correct alignement after each surgery. As a mechanic overload from insufficient correction of the alignement of the spine was ruled out, we believe that the multiple complications were caused by an impairment in the bone structure and thus, reviewing old imaging, diagnosed the patient with spinal RDOA. In case of spinal RDOA, particular care should be placed in the choice of extent and type of instrumentation in order to prevent re-intervention. CONCLUSION: Spinal RDOA is characterized by a quickly developing edema of the vertebral endplates followed by a destruction of the disk space within months from the first diagnosis. The disease progresses in the involved segment and to the adjacent disks despite surgical therapy. The surgical planning should take the impaired bone structure account and the use of large interbody cages or 4-rod constructs should be considered to obtain a stable construct.

Steroids in the Management of Preoperative Neurological Deficits in Metastatic Spine Disease: Results From the EPOSO Study.

OBJECTIVE: Patients presenting with neurological deficit secondary to metastatic epidural spinal cord compression (MESCC) are often treated with surgery in combination with high-dose corticosteroids. Despite steroids being commonly used, the evidence regarding the effect of corticosteroids on patient outcomes is limited. The objective of this study was to describe the effect of corticosteroid use on preoperative neurological function in patients with MESCC. METHODS: Patients who underwent surgery between August 2013 and February 2017 for the treatment of spinal metastases and received steroids to prevent neurologic deficits were included. Data regarding demographics, diagnosis, treatment, neurological function, adverse events, health-related quality of life, and survival were extracted from an international multicenter prospective cohort. RESULTS: A total of 30 patients treated surgically and receiving steroids at baseline were identified. Patients had a mean age of 58.2 years (standard deviation, 11.2 years) at time of surgery. Preoperatively, 50% of the patients experienced deterioration of neurological function, while in 30% neurological function was stable and 20% improved in neurological function. Lengthier steroid use did not correlate with improved or stabilized neurological function. Postoperative adverse events were observed in 18 patients (60%). Patients that stabilized or improved neurologically after steroid use showed a trend towards improved survival at 3- and 24-month postsurgery. CONCLUSION: This study described the effect of steroids on preoperative neurological function in patients with MESCC. Stabilization or improvement of preoperative neurological function occurred in 50% of the patients.

Integrated Custom Composite Polyetheretherketone/Carbon fiber (PEEK/CF) Vertebral Body Replacement (VBR) in the Treatment of Bone Tumors of the Spine: A Preliminary Report From a Multicenter Study.

STUDY DESIGN: Retrospective, multicenter chart, and radiologic review. OBJECTIVE: To present the first case series of bone tumors of the spine surgically reconstructed with a new custom, fully radiolucent, polyetheretherketone/carbon fiber (PEEK/CF) vertebral body replacement (VBR) integrated system. SUMMARY OF BACKGROUND DATA: Surgical resections of spinal tumors result in large defects and local recurrence remains a concern. Current titanium-based implants adversely affects postoperative imaging, directly affects ability to identify tumor recurrence, and for delivery of radiotherapy treatments. PEEK/CF spinal implants allows for improved tumor surveillance, precise pre-radiation Computed Tomography planning, and reduces interference with post-reconstructive adjuvant radiotherapy. METHOD: Thirteen patients with spinal tumors underwent vertebral body resection and reconstruction with an integrated, fully radiolucent, custom PEEK/CF vertebral body replacement, and radiolucent posterior PEEK/CF screw-rod system and/or radiolucent anterior PEEK/CF plate system. Clinical and radiographic data were tabulated. Need for adjuvant radiotherapy determined based on final tissue histology and extent of surgical margins. Postoperative surveillance imaging were reviewed for local tumor recurrence. RESULTS: The ability to integrate the PEEK/CF VBR connected to either the posterior screw-rod system, or anterior plate system provided immediate stability. The VBR was placed directly on cancellous vertebral body surface in 46.2% of cases. Loosening of the distal, or proximal, aspect of posterior system was seen in 15.4% of cases. There was no clinical or radiographic evidence of VBR migration and subsidence at latest follow up. Local recurrence occurred in one (7.7%) patient. CONCLUSION: This is the first series to describe the use of a fully-radiolucent, integrated, PEEK/CF implant system for spinal tumor reconstruction. The use of a PEEK/CF VBR system integrated to either the anterior plate, or posterior screw-rod system is feasible and allows for superior postoperative surveillance imaging and effective delivery of postoperative adjuvant radiotherapy.Level of Evidence: 4.

Calculating Utilities From the Spine Oncology Study Group Outcomes Questionnaire: A Necessity for Economic and Decision Analysis.

STUDY DESIGN: General population utility valuation study. OBJECTIVE: The aim of this study was to develop a technique for calculating utilities from the Spine Oncology Study Group Outcomes Questionnaire v2.0 (SOSGOQ2.0). SUMMARY OF BACKGROUND DATA: The ability to calculate quality-adjusted life-years (QALYs) for metastatic spine disease would enhance treatment decision-making and facilitate economic analysis. QALYs are calculated using utilities. METHODS: Using a hybrid concept-retention and factorial analysis shortening approach, we first shortened the SOSGOQ2.0 to eight items (SOSGOQ-8D). This was done to lessen the cognitive burden of the utility valuation exercise. A general population sample of 2730 adults was then asked to evaluate 12 choice sets based on SOSGOQ-8D health states in a Discrete Choice Experiment. A utility scoring rubric was then developed using a mixed multinomial-logit regression model. RESULTS: We were able to reduce the SOSGOQ2.0 to an SOSGOQ-8D with a mean error of 0.003 and mean absolute error of 3.078 compared to the full questionnaire. The regression model demonstrated good predictive performance and was used to develop a utility scoring rubric. Regression results revealed that participants did not regard all SOSGOQ-8D items as equally important. CONCLUSION: We provide a simple technique for converting the SOSGOQ2.0 to utilities. The ability to evaluate QALYs in metastatic spine disease will facilitate economic analysis and patient counseling. We also quantify the importance of individual SOSGOQ-8D items. Clinicians should heed these findings and offer treatments that maximize function in the most important items.Level of Evidence: 3.

Feasibility of achieving planned surgical margins in primary spine tumor: a PTRON study.

OBJECTIVE: Oncological resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, the execution of a meticulously drafted plan sometimes fails. The objectives of this study were to determine how successful surgical teams are at achieving planned surgical margins and how successful surgeons are in intraoperatively assessing tumor margins. The secondary objective was to identify factors associated with successful execution of planned resection. METHODS: The Primary Tumor Research and Outcomes Network (PTRON) is a multicenter international prospective registry for the management of primary tumors of the spine. Using this registry, the authors compared 1) the planned surgical margin and 2) the intraoperative assessment of the margin by the surgeon with the postoperative assessment of the margin by the pathologist. Univariate analysis was used to assess whether factors such as histology, size, location, previous radiotherapy, and revision surgery were associated with successful execution of the planned margins. RESULTS: Three hundred patients were included. The surgical plan was successfully achieved in 224 (74.7%) patients. The surgeon correctly assessed the intraoperative margins, as reported in the final assessment by the pathologist, in 239 (79.7%) patients. On univariate analysis, no factor had a statistically significant influence on successful achievement of planned margins. CONCLUSIONS: In high-volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with the expected success rate in order to optimize patient management and surgical decision-making.

Primary sclerosing epithelioid fibrosarcoma of the spine: a single-institution experience.

AIMS: To present our experience on spinal sclerosing epithelioid fibrosarcoma (SEF) and review the existing literature pertaining to SEF of the spine. METHODS AND RESULTS: Six cases of spinal SEF were reviewed, and a literature search of all primary SEFs of the spine was performed. All tumours occurred in adults (median age, 41 years) and were located all along the spine, the lumbar vertebrae being the most commonly involved. All patients presented with pain that they had experienced for months. The mean tumour size at diagnosis was 52 mm. Five tumours showed a spectrum of microscopic features consistent with pure SEF, and one showed a hybrid morphology with areas of low-grade fibromyxoid sarcoma. All were diffusely and strongly positive for mucin 4. Two cases were initially misdiagnosed as epithelioid haemangioendothelioma and aggressive chondroblastoma. Fluorescence in-situ hybridisation showed rearrangements of either FUS or EWSR1 in four cases. Reverse transcription polymerase chain reaction showed the presence of FUS-CREB3L1 and EWSR1-CREB3L1 fusion transcripts in two cases and one case, respectively. Of five patients with follow-up data available, two developed one or more local recurrences and three patients had metastatic disease. Distant metastases were mainly to other osseous locations, followed by lungs and lymph nodes. At last follow-up, three patients had died of disease and one was alive with multiple metastases. CONCLUSIONS: SEF is an aggressive sarcoma that can involve the spine. It is important to recognise the spine as the primary location of SEF, in order to avoid misdiagnosis as more common primary spinal neoplasms, which can impact on therapeutic approaches.

Health related quality of life outcomes following surgery and/or radiation for patients with potentially unstable spinal metastases.

BACKGROUND: Currently there is no prospective pain and health related quality of life (HRQOL) data of patients with potentially unstable spinal metastases who were treated with surgery ± radiation or radiation alone. METHODS: An international prospective cohort multicenter study of patients with potentially unstable spinal metastases, defined by a SINS score 7 to 12, treated with surgery ± radiation or radiotherapy alone was conducted. HRQOL was evaluated with the numeric rating scale (NRS) pain score, the SOSGOQ2.0, the SF-36, and the EQ-5D at baseline and 6, 12, 26, and 52 weeks after treatment. RESULTS: A total of 136 patients were treated with surgery ± radiotherapy and 84 with radiotherapy alone. At baseline, surgically treated patients were more likely to have mechanical pain, a lytic lesion, a greater median Spinal Instability Neoplastic score, vertebral compression fracture, lower performance status, HRQOL, and pain scores. From baseline to 12 weeks post-treatment, surgically treated patients experienced a 3.0-point decrease in NRS pain score (95% CI -4.1 to -1.9, p<.001), and a 12.7-point increase in SOSGOQ2.0 score (95% CI 6.3-19.1, p<.001). Patients treated with radiotherapy alone experienced a 1.4-point decrease in the NRS pain score (95% CI -2.9 to 0.0, p=.046) and a 6.2-point increase in SOSGOQ2.0 score (95% CI -2.0 to 14.5, p=.331). Beyond 12 weeks, significant improvements in pain and HRQOL metrics were maintained up to 52-weeks follow-up in the surgical cohort, as compared with no significant changes in the radiotherapy alone cohort. CONCLUSIONS: Patients treated with surgery demonstrated clinically and statistically significant improvements in pain and HRQOL up to 1-year postsurgery. Treatment with radiotherapy alone resulted in improved pain scores, but these were not sustained beyond 3 months and HRQOL outcomes demonstrated nonsignificant changes over time. Within the SINS potentially unstable group, distinct clinical profiles were observed in patients treated with surgery or radiotherapy alone.

Strategy for the Practice of Spine Oncological Surgery During the Covid-19 Pandemic.

STUDY DESIGN: Case series. OBJECTIVE: For each of the most frequent clinical scenarios, the authors reached a consensus on how should be timing and indications be optimized to reduce risk while maintaining the expected outcomes under the Covid-19 pandemics. SUMMARY OF BACKGROUND DATA: The organization of health care has been changed by the Covid-19 pandemic with a direct impact on Spine Oncology Surgery. Emergency surgery is still a priority, but in case of spinal tumors it should be better defined which conditions require emergency treatment. METHODS: An expert panel with general spine surgeons, oncological spine surgeons, and radiation oncologists was formed to analyze the most frequent scenarios in spinal musculoskeletal oncology during Covid-19 pandemics. RESULTS: Spine metastases can be found incidentally during follow-up or can clinically occur by increasing pain, pathologic fracture, and/or neurological symptoms. Primary spine tumors are much more rare and very rarely present with acute onset. The first step is to suspect this rare condition, to avoid to treat a primary tumor as it were a metastasis. Most complex surgery, like en bloc resection, associated with high morbidity and mortality rate for the treatment of low grade malignancy like chordoma or chondrosarcomas, if intensive care unit availability is reduced, can be best delayed some weeks, as not impacting on prognosis, due to the slow growth rate of these conditions. The currently accepted protocols for Ewing sarcoma (ES) and osteogenic sarcoma must be performed for local and systemic disease control. For ES, after the first courses of chemotherapy, radiotherapy can be selected instead of surgery, during Covid-19, to the end of the full course of chemotherapy. In immunocompromised patients, (treated by chemotherapy), it is necessary to avoid contact with affected or exposed people. CONCLUSION: Even more than during normal times, a multidisciplinary approach is mandatory to share the decision to modify a treatment strategy. LEVEL OF EVIDENCE: 5.

Vertebroplasty shows no antitumoral effect on vertebral metastasis: a case-based study on anatomopathological examinations.

PURPOSE: Percutaneous vertebroplasty (VTP) is a well-known surgical technique used for pain management and vertebral consolidation in the treatment of osteolytic metastases of the spine. While this indication is proven and commonly accepted, an antitumoral effect of polymethylmethacrylate (PMMA) has been proposed but not yet demonstrated. The aim of our study is to evaluate the evidences of antitumoral effect on anatomopathological examination. We present a small series of pathology findings after VTP for spine metastases that support the lack of antitumoral effect of PMMA. METHODS: We have retrospectively analyzed three cases of patients treated for en bloc excision of recurrent spine metastases previously submitted elsewhere to VTP on the same levels. We discuss our results with the literature reporting of an antitumoral effect of VTP. RESULTS: In our series, after anatomopathological examination, a cement-induced tumor necrosis was never found. Conversely, a foreign-body reaction around the cement was found, inside vital tumor. These results are consistent with an immune reaction to a foreign body without evidences of an antitumoral effect of PMMA. CONCLUSION: The antitumoral effect of PMMA should not be taken into account as an indication for VTP in spinal metastases. It is important not to misuse VTP as a therapy aiming at tumor control. Other therapies such as radiotherapy, radiosurgery and open surgery are available for that purpose.

Composite PEEK/carbon fiber rods in the treatment for bone tumors of the cervical spine: a case series.

INTRODUCTION: Radiotherapy (RT) is frequently applied as an adjuvant therapy during spinal tumors treatment. Metallic implants can interfere with RT planning and execution, as it is known that metallic implants produce a backscattering effect that can limit RT accuracy and their presence can be associated with unwanted dose increase. PEEK/carbon fiber implants are designed to reduce these problems but their application in the cervical spine is limited, due to the reduced number and types of implants, the screw dimensions and the absence of lateral mass screws. We propose a hybrid system made of carbon rods and screws coupled with subliminal polyester bands with titanium clamps. We designed this hybrid construct to enclose the cervical region in the area of instrumentation without limiting the application of postoperative radiotherapy. MATERIALS AND METHODS: Six patients in which the hybrid hardware was implanted were retrospectively examined. Data on demographics, intraoperative and postoperative events, tumor details and staging and cervical alignment were collected pre- and postoperatively. RESULTS: No intraoperative complications occurred. En bloc resection was performed in two patients, while the remaining four received an intralesional resection. Three out of six patients received postoperative RT, without any alteration in its planning and administration. DISCUSSION AND CONCLUSIONS: Hybrid implants made of composite PEEK/carbon fiber screws and rods and sublaminar bands are a helpful solution for spinal reconstruction in the cervical and cervico-thoracic regions after spine tumor surgery. The implants do not produce artifacts at postoperative images, easing the planning and execution of postoperative radiotherapy.

Surgical or Radiation Therapy for the Treatment of Cervical Spine Metastases: Results From the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) Cohort.

STUDY DESIGN: Ambispective cohort study design. OBJECTIVES: Cervical spine metastases have distinct clinical considerations. The aim of this study was to determine the impact of surgical intervention (± radiotherapy) or radiotherapy alone on health-related quality of life (HRQOL) outcomes in patients treated for cervical metastatic spine tumours. METHODS: Patients treated with surgery and/or radiotherapy for cervical spine metastases were identified from the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) international multicentre prospective observational study. Demographic, diagnostic, treatment, and HRQOL (numerical rating scale [NRS] pain, EQ-5D (3L), SF-36v2, and SOSGOQ) measures were prospectively collected at baseline, 6 weeks, 3 months, and 6 months postintervention. RESULTS: Fifty-five patients treated for cervical metastases were identified: 38 underwent surgery ± radiation and 17 received radiation alone. Surgically treated patients had higher mean spinal instability neoplastic scores compared with the radiation-alone group (13.0 vs 8.0, P < .001) and higher NRS pain scores and lower HRQOL scores compared to the radiation alone group (P < .05). From baseline to 6 months posttreatment, surgically treated patients demonstrated statistically significant improvements in NRS pain, EQ-5D (5L), and SOSGOQ2.0 scores compared with nonsignificant improvements in the radiotherapy alone group. CONCLUSIONS: Surgically treated cervical metastases patients presented with higher levels of instability, worse baseline pain and HRQOL scores compared with patients who underwent radiotherapy alone. Significant improvements in pain and HRQOL were noted for those patients who received surgical intervention. Limited or no improvements were found in those treated with radiotherapy alone.

Revision surgery for tumors of the thoracic and lumbar spine: causes, prevention, and treatment strategy.

INTRODUCTION: Revision surgery in spine tumor surgery can offer peculiar challenges given the severity of the majority of these lesions and the complexity of surgical procedures that are required. MATERIALS AND METHODS AND RESULTS: Based on literature review and on personal experience, surgical site infection, cerebrospinal fluid leakage, tumor recurrence and hardware failures are some of the possible causes of surgical revision in this set of patients. CONCLUSIONS: The aim of this study is to evaluate the most frequent complications that can lead to revision in spine tumor patients, to provide suggestions on how to prevent these events and to offer reasonable strategies to properly plan and perform a revision surgery. These slides can be retrieved under Electronic Supplementary Material.