Spine Instability Neoplastic Score (SINS) as a Predictive Tool in Conventional Radiotherapy: A Narrative Review.

AIMS: This narrative review seeks to identify the SINS score application in the radiation oncology field. METHODS: This literature review was performed searching papers on MEDLINE published from January 2010 to August 2022. RESULTS: In terms of vertebral painful lesions and RT symptomatic responses, the SINS score could be an interesting aid in order to choose the right therapeutic approach. Lesions with higher level of instability, and therefore higher SINS score, could did not find any significant benefit from radiation therapy which is more effective on the tumor-related pain component. For SINS as a predictor of adverse event after RT or its changes after RT, we obtained contrasting results. CONCLUSIONS: The reported few experiences showed ambiguous conclusions. Further prospective studies are needed.

Prospective Evaluation of the Relationship Between Mechanical Stability and Response to Palliative Radiotherapy for Symptomatic Spinal Metastases.

BACKGROUND: A substantial number of patients with spinal metastases experience no treatment effect from palliative radiotherapy. Mechanical spinal instability, due to metastatic disease, could be associated with failed pain control following radiotherapy. This study investigates the relationship between the degree of spinal instability, as defined by the Spinal Instability Neoplastic Score (SINS), and response to radiotherapy in patients with symptomatic spinal metastases in a multi-institutional cohort. METHODS AND MATERIALS: The SINS of 155 patients with painful thoracic, lumbar, or lumbosacral metastases from two tertiary hospitals was calculated using images from radiotherapy planning CT scans. Patient-reported pain response, available for 124 patients, was prospectively assessed. Pain response was categorized, according to international guidelines, as complete, partial, indeterminate, or progression of pain. The association between SINS and pain response was estimated by multivariable logistic regression analysis, correcting for predetermined clinical variables. RESULTS: Of the 124 patients, 16 patients experienced a complete response and 65 patients experienced a partial response. Spinal Instability Neoplastic Score was associated with a complete pain response (adjusted odds-radio [ORadj] 0.78; 95% confidence interval [CI] 0.62-0.98), but not with an overall pain response (ORadj 0.94; 95% CI 0.81-1.10). CONCLUSIONS: A lower SINS, indicating spinal stability, is associated with a complete pain response to radiotherapy. This supports the hypothesis that pain resulting from mechanical spinal instability responds less well to radiotherapy compared with pain from local tumor activity. No association could be determined between SINS and an overall pain response, which might indicate that this referral tool is not yet optimal for prediction of treatment outcome. IMPLICATIONS FOR PRACTICE: Patients with stable painful spinal metastases, as indicated by a Spinal Instability Neoplastic Score (SINS) of 6 or lower, can effectively be treated with palliative external beam radiotherapy. The majority of patients with (impending) spinal instability, as indicated by a SINS score of 7 or higher, will achieve a (partial) response after palliative radiotherapy; however, some patients might require surgical intervention. Therefore, it is recommended to refer patients with a SINS score of 7 or higher to a spine surgeon to evaluate the need for surgical intervention.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. IMPLICATIONS FOR PRACTICE: 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.

[Reconstruction of the ligamentum cruciatum anterius during the performance of unicondylar knee arthroplasty by minimally invasive surgery. A salvage procedure for monocondylar arthrosis and downfall of the anterior cruciate ligament]. / Additive Kreuzbandplastik bei der Implantation von unikondylären Endoprothesen mittels Miniarthrotomie. Eine Lösungsmöglichkeit bei unilateralen Arthrosen mit Kreuzbandverlust.

Opinions differ on unicompartmental knee replacement for treatment of unicompartmental ostearthritis of the knee. There is general agreement that well-functioning cruciate ligaments are necessary if use of this prosthesis is to be successful. Especially for younger people who are still working and who have advanced medial arthritis and lacking or inadequate anterior cruciate ligament, this therapy has its limitations. To exploit the advantages of unicondylar replacement in such patients, we combined this joint replacement operation with reconstruction of the anterior cruciate ligament using the semitendinosus/gracilis tendon and applying a transfix technique in 7 cases. The mean Knee Society Score was recorded preoperatively and after 12 and 28 months of follow-up. Long-term results are not yet available, but after this operation method average Knee Society Scores of 164.1 were recorded at 28 months, and all these patients were able to return to work after their rehabilitation. Thus, the short-term follow-up documents the efficacity of the treatment and benefit to the patients.

Monopolar thermal treatment of symptomatic anterior cruciate ligament instability.

Patients with anterior cruciate ligament instability resulting from incomplete tears or elongation in continuity without ligament detachment historically have been treated conservatively or by graft replacement. The literature is sparse regarding alternative treatments. The current study presents experience using monopolar thermal repair on 28 consecutive knees with partial anterior cruciate ligament tears all symptomatically unstable. All lesions were less than 6 months old (average, 77 days; range, 7-180 days) and with a difference of 6 mm or more (average, 9 mm; range, 6-13 mm) when comparing both knees using KT-1000 evaluation. Incomplete tears of the anterior cruciate ligament were seen at arthroscopic evaluation. The rehabilitation protocol included use of a brace for at least 6 weeks and progressive weightbearing. A 2-year minimum followup (range, 24-35 months) was done in all patients following the International Knee Documentation Committee guidelines. The overall outcome was normal or nearly normal in 96% of the patients. One failure occurred at 8 weeks. Twenty-six knees had a KT-1000 difference between 0 and 2 mm (average, 1.9 mm). Because thermal application causes death to some of the cells directly treated, it should be taken into account in selection and application. Immediately after thermal use, the anterior cruciate ligament, although thicker and tighter, is at first weaker than normal. Rehabilitation and compliance are critical during early ligament healing. This procedure seems to be a reasonable alternative to anterior cruciate ligament grafting in selected patients.

Tightening elongated ACL grafts by application of bipolar electromagnetic energy (ligament shrinkage).

In ACL transplants showing elongation with functional deficit but no interruption of structure (Marburg Arthroscopic Score type III) there is the possibility of reinsertion, augmentation, or revision ACL reconstruction to stabilize the joint. Bipolar electromagnetic energy can be used to induce the tightening of elongated ACL transplants. We examined 14 patients with a secondary instability after ACL transplantation (mean 23.6 months). During arthroscopy a type III transplant without signs of nonisometric position was found. The elongated transplants were treated by bipolar application probe. All knees where protected by an unlimited orthosis over a period of 12 weeks. Postoperative follow-up took 9.4 months. There was a significant improvement in subjective discomforts (35.9 to 88.5 points on the Lysholm score), and the Rollimeter test showed a reduction of the ventral tibial translation (13.1 to 2.6 mm). There was a correlation between the degree of chondral damage and a Lysholm score but not between subjective discomforts and the degree of instability. Our findings confirm that elongated ACL transplants can be tightened by applying bipolar electromagnetic energy during rearthroscopy, thus avoiding revision ACL reconstruction in some cases.

Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis.

Despite many efforts, there is no clear and widely accepted definition of lumbar instability because there are no unquestionable and currently applicable clinical or radiologic criteria available for this entity. This article reviews the current concepts of lumbar instability and the different imaging modalities used to make the diagnosis as evident as possible.

The biologic response to laser thermal modification in an in vivo sheep model.

The purpose of this study was to evaluate the effect of nonablative laser energy on mechanical, histologic, ultrastructural, and biochemical properties of joint capsular tissue in an in vivo sheep model. Femoropatellar joint capsule was treated with the holmium:yttrium-aluminum-garnet laser via an arthroscope, and tissues were harvested immediately after surgery, or at 3, 7, 14, 30, 60, 90, and 180 days after surgery (n = 8/group). Laser treatment caused significant decreases in tissue stiffness from 0 to 7 days after surgery, then stiffness gradually increased after 14 days. Tissue strength was lowest 3 days after laser treatment. Histologic examination revealed immediate collagen hyalinization and cell necrosis, followed by active cellular response characterized by extensive fibroblast migration and capillary sprouting. Tissue appeared to be normal histologically 60 days after surgery; however, collagen fibrils remained uniformly small. This study showed an active tissue response secondary to thermal modification with concomitant recovery of mechanical properties by 30 days after surgery. Whether the shrinkage or joint stability was maintained with time remains to be evaluated. To clarify the advantages and disadvantages of this technique, a carefully controlled clinical trial with long term followup should be performed.