Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies.

BACKGROUND: Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care. METHODS: A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients' pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality. RESULTS: The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates. CONCLUSIONS: Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes. TRIAL REGISTRATION: PROSPERO registration number: CRD42020145151 .

A Personalized Medicine Approach for the Management of Spinal Metastases with Cord Compression: Development of a Novel Clinical Prediction Model for Postoperative Survival and Quality of Life.

Surgery should be considered for patients with metastatic epidural spinal cord compression (MESCC) with a life expectancy of ≥3 months. Given the heterogeneity of the clinical presentation and outcomes, clinical prognostic models (CPMs) can assist in tailoring a personalized medicine approach to optimize surgical decision-making. We aimed to develop and internally validate the first CPM of health-related quality of life (HRQoL) and a novel CPM to predict the survival of patients with MESCC treated surgically. Using data from 258 patients (AOSpine North America MESCC study and Nottingham MESCC registry), we created 1-year survival and HRQoL CPMs using a Cox model and logistic regression analysis with manual backward elimination. The outcome measure for HRQoL was the minimal clinical important difference in EuroQol 5-dimension questionnaire scores. Internal validation involved 200 bootstrap iterations, and calibration and discrimination were evaluated. Longer survival was associated with a higher SF-36 physical component score (hazard ratio [HR], 0.96). In contrast, primary tumor other than breast, thyroid, or prostate (unfavorable: HR, 2.57; other: HR, 1.20), organ metastasis (HR, 1.51), male sex (HR, 1.58), and preoperative radiotherapy (HR, 1.53) were not (c-statistic, 0.69; 95% confidence interval, 0.64-0.73). Karnofsky performance status <70% (odds ratio [OR], 2.50), living in North America (OR, 4.06), SF-36 physical component score (OR, 0.95) and SF-36 mental component score (OR, 0.96) were associated with the likelihood of achieving a minimal clinical important difference improvement in the EuroQol 5-Dimension Questionnaire score at 3 months (c-statistic, 0.74; 95% confidence interval, 0.68-0.79). The calibration for both CPMs was very good. We developed and internally validated the first CPMs of survival and HRQoL at 3 months postoperatively in patients with MESCC using the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) guidelines. A web-based calculator is available (available at: http://spine-met.com) to assist with clinical decision-making.

Quality of life, pain, and psychological factors in patients undergoing surgery for primary tumors of the spine.

PURPOSE: Knowledge about quality of life (QOL), pain, and psychological factors in patients with primary tumors of the spine is limited, but is important in planning rehabilitation after surgery. Aims of this study were to assess the preoperative levels and improvement after surgery of these factors, and to identify the predictors of postoperative pain and QOL. METHODS: Patients with primary tumors undergoing spine surgery were matched for sex and age with patients with metastatic tumors. QOL was measured at baseline and three months after surgery with the physical (PCS) and mental (MCS) components SF-12 subscales, pain intensity with a numeric rating scale (NRS), depression with the Beck Depression Inventory (BDI). Preoperative SF-12, NRS, and BDI levels and differences in follow-up improvement in SF-12 and NRS were compared across samples. LASSO regressions were performed to find predictors of follow-up SF-12 and NRS. RESULTS: Patients with primary tumors showed better PCS and NRS, and similar BDI and MCS than patients with metastatic tumors. At follow-up, they showed stronger improvement in the MCS and no improvement in the PCS. All QOL scores were below those of the general population. Follow-up PCS was predicted by baseline PCS and BDI; MCS by baseline MCS; pain intensity by baseline pain intensity and BDI. CONCLUSION: Patients with primary tumors of the spine suffer from moderate levels of physical and mental impairment. Depression influences surgical outcomes.

An Evaluation of PROMIS in Patients With Primary or Metastatic Spine Tumors.

STUDY DESIGN: Retrospective evaluation of prospectively collected data. OBJECTIVE: In spine tumor patients: i) to assess the correlation of Patient-reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores; and ii) to assess ceiling and floor effects of PROMIS PF, PI, and Depression domains and the ODI/NDI. SUMMARY OF BACKGROUND DATA: There remains no widely used patient-reported outcome (PRO) instrument for spine tumor patients. PROMIS, a universal PRO tool, may add notable value to patient care. A paucity of work exists comparing PROMIS to legacy PRO tools in primary and metastatic spine tumor patients. METHODS: Patients confirmed to have a primary or metastatic spine tumor were asked to complete PROMIS PF, PI, and Depression domains and either an ODI or NDI questionnaire between May 2015 and December 2017. Pearson correlation coefficients (r) were calculated. Ceiling and floor effects were determined. P < 0.05 was significant. RESULTS: Eighty unique visits from 51 patients with spine tumors (44 metastatic/67 visits; 7 primary/13 visits) met our inclusion criteria. A strong correlation existed between PROMIS PI and the ODI/NDI in both primary and metastatic tumor patient subgroups (range, r = 0.75-0.86, P < 0.05). PROMIS PF and the ODI/NDI demonstrated a strong correlation among all patients (r = -0.75, P < 0.05) and in the metastatic disease subgroup (r = -0.78, P < 0.05). A strong correlation existed between PROMIS Depression and the ODI/NDI in the primary tumor subgroup (r = 0.79, P < 0.05). PROMIS Depression demonstrated the largest floor effect (13.6%); there were similar ceiling effects. CONCLUSION: PROMIS PF and PI domains correlate well with the ODI/NDI in spine tumor patients and have a similar ceiling effect but decreased floor effect. PROMIS Depression was not as well captured, except in the primary tumor subgroup. LEVEL OF EVIDENCE: 2.

Survival, local control, and health-related quality of life in patients with oligometastatic and polymetastatic spinal tumors: A multicenter, international study.

BACKGROUND: The treatment of oligometastatic (≤5 metastases) spinal disease has trended toward ablative therapies, yet to the authors' knowledge little is known regarding the prognosis of patients presenting with oligometastatic spinal disease and the value of this approach. The objective of the current study was to compare the survival and clinical outcomes of patients with cancer with oligometastatic spinal disease with those of patients with polymetastatic (>5 metastases) disease. METHODS: The current study was an international, multicenter, prospective study. Patients who were admitted to a participating spine center with a diagnosis of spinal metastases and who underwent surgical intervention and/or radiotherapy between August 2013 and May 2017 were included. Data collected included demographics, overall survival, local control, and treatment information including surgical, radiotherapy, and systemic therapy details. Health-related quality of life (HRQOL) measures included the EuroQOL 5 dimensions 3-level questionnaire (EQ-5D-3L), the 36-Item Short Form Health Survey (SF-36v2), and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ). RESULTS: Of the 393 patients included in the current study, 215 presented with oligometastatic disease and 178 presented with polymetastatic disease. A significant survival advantage of 90.1% versus 77.3% at 3 months and 77.0% versus 65.1% at 6 months from the time of treatment was found for patients presenting with oligometastatic disease compared with those with polymetastatic disease. It is important to note that both groups experienced significant improvements in multiple HRQOL measures at 6 months after treatment, with no differences in these outcome measures noted between the 2 groups. CONCLUSIONS: The treatment of oligometastatic disease appears to offer a significant survival advantage compared with polymetastatic disease, regardless of treatment choice. HRQOL measures were found to improve in both groups, demonstrating a palliative benefit for all treated patients.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy.

BACKGROUND: Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL). METHODS: A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit. RESULTS: The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions. DISCUSSION: Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri­operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

Are older patients with solitary spinal metastases fit for total en-bloc surgery?

OBJECTIVE: Due to radical resection, total en-bloc spondylectomy (TES) is associated with significant levels of surgical injury and spinal instability, particularly in elderly patients with solitary spinal metastases (SM), whether the possible benefits outweigh the risk requires intense consideration. Our aim was to compare and analyze the impact of age on patient prognosis. PATIENTS AND METHODS: This study investigated TES in 78 consecutive patients with solitary SM, who were divided into Group A (>65 years, n = 32) and group B (<60 years of age, n = 46). Surgical outcomes were assessed according to survival time, local recurrence, neurological function, pain, and quality of life before and after surgery. Differences between groups were statistically compared using analysis of variance (ANOVA) or chi-square tests. RESULTS: There was no significant difference between the two groups in terms of surgery duration, blood loss, blood transfusion or the duration of hospital stay (p > 0.05). Furthermore, there was no significant difference in the median survival time between the two groups (p > 0.05). However, the perioperative complication rate in group A was higher than that in group B (p < 0.05). There was no significant difference in terms of local recurrence rate when compared between group A and group B (p > 0.05), and there were no significant differences in terms of improvements in neurological function, Visual Analogue Scale and Karnofsky scores of patients between the two groups (p > 0.05). CONCLUSION: Older patients can experience survival and local recurrence rates that were similar to those of younger patients. Although older patients are at increased risk of perioperative complications, this factor does not appear to lead to serious adverse outcomes. Older patients are still good candidates to receive TES to cure solitary SM after careful preparation and strict selection.

Psychometric evaluation and adaptation of the Spine Oncology Study Group Outcomes Questionnaire to evaluate health-related quality of life in patients with spinal metastases.

BACKGROUND: The Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ) was developed as the first spine oncology-specific health-related quality of life (HRQOL) measure. This study evaluated the psychometric properties and clinical validity of the SOSGOQ in a diverse cohort of patients with spinal metastases. METHODS: An international, multicenter, prospective observational cohort study including patients with spinal metastases who underwent surgery and/or radiotherapy was conducted by the AOSpine Knowledge Forum Tumor. Demographic, tumor, and treatment data were collected. HRQOL was evaluated using the SOSGOQ and Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) at baseline and fixed follow-up times. Construct validity was assessed using multitrait scaling analyses, confirmatory factor analyses, and correlation with the SF-36 and NRS pain score. Test-retest reliability was assessed in a subgroup of patients between 12 weeks after treatment and the retest 4 to 9 days later. RESULTS: A total of 238 patients were enrolled at 9 centers across North America; 153 of these patients had HRQOL data available at 12 weeks after treatment. Multitrait scaling analyses and confirmatory factor analyses resulted in a refined version of the SOSGOQ with 4 domains and 4 single items. The revised SOSGOQ (SOSGOQ2.0) demonstrated strong correlations with SF-36 and the ability to discriminate between clinically distinct patient groups. Reliability of the SOSGOQ2.0 was demonstrated to be good, with an intraclass correlation coefficient ranging from 0.58 to 0.92 for the different domains. CONCLUSIONS: The SOSGOQ2.0 is a reliable and valid measure with which to evaluate HRQOL in patients with spinal metastases. It is recommended to use the SOSGOQ2.0 together with a generic HRQOL outcome measure to comprehensively assess HRQOL and increase sensitivity and specificity. Cancer 2018;124:1828-38. © 2018 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Clinical Results of Minimally Invasive Spine Stabilization for Spinal Metastases.

The goal of the study was to evaluate minimally invasive palliative surgery and the effect of postoperative adjuvant therapy for metastatic spinal tumor with a limited vital prognosis. Of the 70 patients who underwent palliative surgery for metastatic spinal tumor at the authors' hospital between March 2012 and May 2016, thirty-three were treated with minimally invasive spine stabilization (MISt) using percutaneous pedicle screws (PPSs) and included in the current study. Of the 33 patients, 26 were men and 7 were women; mean age at surgery was 68.6 years. Intraoperatively, posterior decompression and fusion was performed in 17 (51.5%) patients and fusion only was performed in 16 (48.5%). Mean operative time was 202.5 minutes, mean intraoperative blood loss was 331.6 mL, and intraoperative blood loss was 1500 mL or greater in 2 (6.1%) patients. Median postoperative survival time determined using the Kaplan-Meier method was 11.0 months (95% confidence interval, 7.3-14.6). Regarding improvement of paralysis, neurological deficit was improved by at least 1 Frankel grade for 15 (45.5%) patients, and the number of ambulatory patients increased from 22 (66.7%) to 25 (75.8%). Postoperative adjuvant therapy included chemotherapy in 17 (51.5%) patients, radiotherapy in 21 (63.6%), and bone-modifying agent treatment in 25 (75.8%). The mean Barthel Index for activities of daily living improved from 53.5 preoperatively to 71.5 postoperatively. Discharge to home was possible for 23 (69.7%) patients. Activities of daily living for patients with metastatic spinal tumor were improved by minimally invasive palliative surgery with MISt using PPSs and postoperative adjuvant therapy. [Orthopedics. 2017; 40(4):e693-e698.].

Postoperative quality-of-life assessment in patients with spine metastases treated with long-segment pedicle-screw fixation.

OBJECTIVE In recent decades, progress in the medical management of cancer has been significant, resulting in considerable extension of survival for patients with metastatic disease. This has, in turn, led to increased attention to the optimal surgical management of bone lesions, including metastases to the spine. In addition, there has been a shift in focus toward improving quality of life and reducing hospital stay for these patients, and many minimally invasive techniques have been introduced with the aim of reducing the morbidity associated with more traditional open approaches. The goal of this study was to assess the efficacy of long-segment percutaneous pedicle screw stabilization for the treatment of instability associated with thoracolumbar spine metastases in neurologically intact patients. METHODS This study was a retrospective review of data from a prospective database. The authors analyzed cases in which long-segment percutaneous pedicle screw fixation was performed for the palliative treatment of thoracolumbar spinal instability due to spinal metastases in neurologically intact patients. All of the patients included in the study underwent surgery between January 2014 and May 2015 at the authors' institution. Postoperative radiation therapy was planned within 10 days following the stabilization in all cases. Clinical and radiological follow-up assessments were planned for 3 days, 3 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. Outcome was assessed by means of standard postoperative evaluation and oncological and spinal quality of life measures (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 [EORTC QLQ-C30] and Oswestry Disability Index [ODI], respectively). Moreover, 5 patients were given an activity monitoring device for recording the distance walked daily; preoperative and postoperative daily distances were compared. RESULTS Data from 17 cases were analyzed. There were no complications, and patients showed improvement in pain level and quality of life from the early postoperative period on. The mean ODI score was 62.7 (range 40-84) preoperatively, 35.4 (range 24-59) on postoperative Day 3, and 46.1 (range 30-76) at 3 weeks, 37.6 (range 25-59) at 6 weeks, 34.0 (range 24-59) at 3 months, 39.1 (range 22-64) at 6 months, and 30.0 (range 20-55) at 1 year after screw placement. The mean ODI was significantly improved in the first 45 days (p < 0.001). Improvement was also evident in scores for functional and symptomatic scales of the EORTC QLQ-C30. All patients underwent postoperative radiation therapy within 10 days (mean 7.5). All patients (n = 5) with an activity monitoring device showed improvement in daily walking distance. CONCLUSIONS Less-invasive palliative treatment for advanced spinal metastases is promising as part of a multidisciplinary approach to the care of patients with metastatic disease. The results of this study indicate that percutaneous surgery may allow for rapid improvement in quality of life and walking ability for patients with thoracolumbar instability due to spine metastases. Long-segment percutaneous screw fixation followed by early radiation therapy appears to be a safe and effective treatment option for providing solid and durable stability and improved quality of life for these patients.

A Cross-sectional Study on the Symptom Burden of Patients With Spinal Tumor: Validation of the Chinese Version of the M.D. Anderson Symptom Inventory-Spine Tumor Module.

CONTEXT: Tumors involving the spine are associated with unique symptoms affecting both patient survival and health-related quality of life. Currently, there is no disease-specific instrument in Chinese to assess the symptom burden of these patients. OBJECTIVES: The objective of this study was to translate and validate a Chinese version of the M.D. Anderson Symptom Inventory-Spine Tumor Module (MDASI-SP-C) to assess the symptom burden of Chinese-speaking patients with spinal tumors. METHODS: MDASI-SP-C was forward-and-backward translated according to standard protocols and administered to patients fulfilling study criteria at a major referral center of spine tumor between November 2014 and September 2015. The generic instruments of Short Form 36 Quality of Life Questionnaire (SF-36), Functional Assessment of Cancer Therapy-General Version (FACT-G), and Karnofsky Performance Scale were used along with MDASI-SP-C. Prevalence and severity distribution of each item were analyzed. Psychometric assessment and hierarchical cluster analysis were performed for the translated instrument. RESULTS: One hundred forty-two patients were enrolled. High interdependency and relatively low intra-cluster distances were identified. Cronbach's alpha of the entire instrument, the symptom severity subscale, and the interference subscale was 0.93, 0.91, and 0.92, respectively. Principal axis factoring resulted in a four-factor solution, which was reduced to a three-factor (general symptoms, spine-specific symptoms, and gastrointestinal symptoms) solution on account of clinical interpretation. Correlation coefficients between MDASI-SP-C items and their corresponding domains in SF-36 and/or FACT-G were all greater than 0.3. MDASI-SP-C was able to distinguish patients with different Karnofsky Performance Scale levels. CONCLUSION: MDASI-SP-C demonstrated satisfactory psychometric properties and could be used to better assess the symptom burden of Chinese-speaking patients with spine tumors for improved management of their medical needs.

Quality of life after different surgical procedures for the treatment of spinal metastases: results of a single-center prospective case series.

OBJECTIVE The performance of surgery for spinal metastases is rapidly increasing. Different surgical procedures, ranging from stabilization alone to stabilization combined with corpectomy, are thereby performed for various indications. Little is known about the impact of these different procedures on patient quality of life (QOL), but this factor is crucial when discussing the various therapeutic options with patients and their families. Thus, the authors of this study investigated the effect of various surgical procedures for spinal metastases on patient QOL. METHODS The authors prospectively followed a cohort of 113 patients with spinal metastases who were referred to their clinic for surgical evaluation between July 2012 and July 2014. Quality of life was assessed using the EQ-5D at intake and at 3, 6, 9, and 12 months after treatment. RESULTS Nineteen patients were treated conservatively, 41 underwent decompressive surgery with or without stabilization, 47 underwent a piecemeal corpectomy procedure with stabilization and expandable cage reconstruction, and 6 had a stabilization procedure without decompression. Among all surgical patients, the mean EQ-5D score was significantly increased from 0.44 pretreatment to 0.59 at 3 months after treatment (p < 0.001). Mean EQ-5D scores at 1 year after surgery further increased to 0.84 following decompression with stabilization, 0.74 after corpectomy with stabilization, and 0.94 after stabilization without decompression. Frankel scores also improved after surgery. There were no significant differences in improvements in EQ-5D scores and Frankel grades among the different surgical procedures. In addition, mortality and complication rates were similar. CONCLUSIONS Quality of life can improve significantly after various extensive and less extensive surgical procedures in patients with spinal metastases. The relatively invasive corpectomy procedure, as compared with alternative less invasive techniques, does not negatively affect outcome.

Stereotactic versus conventional radiotherapy for pain reduction and quality of life in spinal metastases: study protocol for a randomized controlled trial.

BACKGROUND: Painful spinal metastases have been treated with conventional radiotherapy for decades, but one-third of the patients have insufficient pain relief after treatment and one-fifth need retreatment. Stereotactic radiotherapy is a method to increase the dose in the spinal metastases with a potentially longer lasting palliative effect without increasing the side effects of the treatment and thereby is expected to improve the quality of life significantly. METHODS/DESIGN: This study is a multicenter prospective randomized clinical trial comparing conventional radiotherapy (1 x 8 Gy) with stereotactic radiotherapy (1 x 20 Gy) for pain reduction and quality of life in patients with painful spinal metastases. A total of 386 patients will be randomized between the two treatment groups. Besides pain measured by the Dutch Brief Pain Inventory, quality of life and cost-effectiveness also will be measured. The primary outcome is pain reduction at 6 weeks after treatment. Secondary outcomes will be the time to pain response, duration of pain relief, health-related quality of life and toxicity, as well as cost-effectiveness. DISCUSSION: This study investigates whether stereotactic radiotherapy with dose escalation for symptomatic spinal metastases can lead to improved pain reduction as compared to conventional radiotherapy without an increase of treatment-related side effects. These results will contribute to the optimization and individualization of the treatment for the patient. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02407795 (March 31, 2015).

Quality of Life and Surgical Outcomes After Soft-Tissue Reconstruction of Complex Oncologic Defects of the Spine and Sacrum.

BACKGROUND: Tumor-related spinal surgery has been revolutionized by recent advances in spinal stabilization, modern neuroimaging, and perioperative intensive medicine. This study examines clinical outcomes and factors associated with complications following reconstruction of complex oncologic defects of the spine and sacrum, in an attempt to increase preoperative recognition of high-risk patients with diminished wound-healing capacity and to optimize clinical outcomes in this cohort. METHODS: We performed a retrospective analysis of fifty-five consecutive patients who underwent soft-tissue reconstruction with or without osseous stabilization of defects following spinal or sacral tumor resection at a quaternary referral center over a twelve-year period. Surgical outcomes included the prevalence of postoperative complications and success of wound closure at the latest follow-up. Health-related quality-of-life outcomes were assessed using the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer 30-Item Core Quality of Life Questionnaire) and SF-36 (Short Form-36) questionnaires. RESULTS: The mean age of the cohort was 46.7 years (range, eighteen to seventy-one years), with a male preponderance (3:1). Soft-tissue reconstructions (n = 70 flaps) were performed in the fifty-five patients. Overall, 36.3% of patients had wound complications. There was a twofold higher wound complication rate after delayed (60%) compared with immediate (29%) reconstruction (p = 0.03). Patients undergoing delayed reconstruction reported significantly lower SF-36 and EORTC QLQ-C30 scores. CONCLUSIONS: Orthoplastic management of spinal tumors should involve a strategy for preoperative recognition of patients at risk of compromised wound-healing. Prophylactic soft-tissue reconstruction can achieve stable definitive wound closure and potentially avoid the need for secondary procedures in appropriately selected patients. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical curative effect of percutaneous vertebroplasty combined with 125I-seed implantation in treating spinal metastatic tumor.

This paper selected and studied 15 in-hospital patients to analyze and discuss the clinical curative effect of percutaneous vertebroplasty (PVP) combined with (125)I-seed implantation in treating spinal metastatic tumor. The evaluation of clinical curative effects was based on the observation of several factors, namely recovery conditions of vertebral body's leading edge and middle section before and after surgery, improvements of kyphosis Cobb angle, visual analog scale (VAS), and Barthel Index (BI). The paper found significant difference between preoperative VAS and postoperative VAS, and the same situation occurred to BI. However, compared to the loss rate of vertebral body's leading edge and middle section and the improvement of Cobb angle before operative, postoperative loss rate and Cobb angle did not show statistical difference. Thus the conclusion is that PVP combined with (125)I-seed implantation is a minimally invasive surgery for effectively treating spinal metastatic tumor, which does well in rapidly releasing pains, improving patients' daily life activities and life qualities.

Evaluation and treatment of spinal metastatic disease.

With the increased survival of oncologic patients, evaluation and management of patients with spinal metastasis is crucial to reducing morbidity and maximizing function. In this chapter, we present some guidelines for the initial systematic evaluation of patients with spinal lesions, as well as the risks, benefits, and alternatives to nonoperative and operative management of metastatic spinal disease, and the overall survival of these patients.

Quality of life and fatigue of patients with spinal bone metastases under combined treatment with resistance training and radiation therapy- a randomized pilot trial.

BACKGROUND: The aim of this trial was to compare the effects of resistance training versus passive physical therapy on quality of life (QoL), fatigue, and emotional distress outcomes during radiation therapy in patients with spinal bone metastases under radiotherapy (RT). METHODS: In this randomized trial, 60 patients were treated from September 2011 until March 2013 into one of the two groups: isometric resistance training or physical therapy with thirty patients in each group during RT. EORTC QLQ-BM22, EORTC QLQ-FA13, and FBK-R10 were assessed at baseline, three months, and six months after RT. RESULTS: Psychosocial aspects in resistance training group (Arm A) were significantly improved after three (p = 0.001) and six months (p = 0.010). Other rated items of the QLQ-BM22 painful site, and pain characteristics were without significant differences. Functional interference showed a positive trend after six months (p = 0.081). After six months, physical fatigue (p = 0.013), and interference with daily life (p = 0.006) according to the QLQ-FA13 assessment improved in Arm A significantly. Emotional distress was in Arm A lower after six months (p = 0.016). The Cohen's effect size confirmed the clinically significant improvement of these findings. CONCLUSIONS: In this group of patients we were able to show that guided isometric resistance training of the paravertebral muscles can improve functional capacity, reduce fatigue and thereby enhance QoL over a 6-months period in patients with stable spinal metastases. The results offer a rationale for future large controlled investigations to confirm these findings. TRIAL REGISTRATION: Clinical trial identifier NCT01409720.

The long-term psychosocial outcomes following excision of sacrococcygeal teratoma: a national study.

OBJECTIVE: The overall effect of the reported long-term sequelae following sacrococcygeal teratoma (SCT) excision on the psychosocial and sexual development has not been addressed appropriately in the literature. The aim of this study was to evaluate the psychosocial adjustment of a national cohort of SCT patients using a validated psychosocial questionnaire. METHODS: Three paediatric surgery centres in Scotland were contacted to identify those SCT patients who were now 5 years or older. The main outcome measure was the Derriford Appearance Scale 59 (DAS-59) which assesses concerns of everyday living, personal relationships, self-esteem and emotional distress. Following ethical approval, age appropriate invitation letters and information sheets for both parents and patients were sent to prospective participants. Parents/patients were contacted after 2 weeks to arrange an interview to complete the questionnaire. RESULTS: 31/48 (65%) of patients identified with SCT completed the DAS-59. Participant ages ranged from 5 to 35 years (median 12 years). 5/31 (16%) were malignant cases. There were 25 (81%) female participants and 12 (39%) patients older than 16 years. 9/31 (29%) participants indicated concern over their appearance. However, we found low levels of appearance-related distress and overall participants showed positive adjustment to personal relationships and everyday living on the DAS-59. CONCLUSIONS: This is the first study looking at the psychosocial adjustment of patients with SCT using a validated psychosocial questionnaire. Encouragingly, we found low levels of appearance-related distress. Future research could identify those factors associated with increased risk of poorer outcomes and highlight those in need of psychological intervention.

Assessment of quality of life after surgery for spinal metastases: position statement of the Global Spine Tumour Study Group.

OBJECTIVE: To review suitable measures of patient-assessed outcome of surgery for spinal metastases, and suggest the Health-Related Quality of Life measures that are useful and practical for this group of patients. METHODS: Surgery for metastatic spinal tumors is becoming more common, but the impact of surgery on the patient, as determined by patient-assessed outcome measures, is not well known. The authors of this article include members of the Global Spine Tumour Study Group: an international group of spinal surgeons who are studying the techniques and outcomes of surgery for spinal tumors. During the development of a research database for the study of patients undergoing surgery for spinal metastases, the different outcome measures were discussed by a panel of spinal surgeons, and quality of life measures were chosen for inclusion, based on expert opinion and literature review. RESULTS: Several different measures are available to assess outcome after spinal surgery for metastatic disease, each with specific advantages and limitations, which are discussed. Our position is to use the EuroQoL EQ-5D questionnaire, because of its simplicity and reliability. CONCLUSIONS: We recommend the use of the EQ-5D measure in research for assessment of patient-centered outcomes and calculation of cost effectiveness of surgery for spinal metastases. Routine use of the measure in clinical practice is also encouraged, because it is a simple and quick method to assess overall clinical outcome.

Reversible delirium in an advanced cancer patient.

Delirium is still one of the most common and distressing symptoms in palliative care patients. Causes and pathophysiology of this neuropsychiatric dysfunction are multifactorial. Recent studies indicate that the interaction of special triggers facilitates development of delirium. Some of them are reversible. This case report presents a reversible delirium in an advanced cancer patient and offers a list of possible delirogen medications. This list might be useful to prevent delirium, particularly in older people.