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Background Context The current standard of care for prediction of survival of cancer staging is based on TNM staging. However, for patients with spinal metastasis, who all have identical stage IV disease, identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. Analytical morphometrics enables physicians to quantify patient frailty by measuring lean muscle mass. Morphometrics also predicts survival in patients with lung cancer metastases to the spine. Purpose Our study evaluates whether morphometrics is predictive of survival in patients with breast cancer spinal metastasis. Design This is an observational retrospective cohort study. Patient Sample This study includes female patients with breast cancer spinal metastases and patients who have undergone stereotactic body radiation therapy. Outcome Measures Overall survival was the primary outcome measure. Methods Morphometric measurements of the psoas muscle were taken using computed tomography scans of the lumbar spine. We then stratified patients into tertiles based on the psoas muscle area. Results We identified 118 patients, with a median survival of 104 days (95% confidence interval [CI]=73–157 days). Overall survival was not associated with age, chemotherapy, or number of levels radiated. Patients in the lowest tertile of psoas size had significantly shorter survival compared with the highest tertile (68 days versus 148 days, hazard ratio 1.76 [95% CI=1.08–2.89], p=.024). The shorter survival was also true for the lowest tertile versus the middle tertile (68 days versus 167 days, hazard ratio 1.95 [95% CI=1.19–3.19], p=.007). Kaplan-Meier survival curves were used to visually illustrate the differences in survival between different tertiles. Conclusions Morphometric analysis of the psoas muscle size in patients with breast cancer metastases to the spine was effective in identifying patients at risk of shorter survival. Further research is needed to validate these results, as well as to see if these methodologies can be applied to other cancer histologies.

Background context Idiopathic spinal cord herniation (ISCH) is an underrecognized entity that is often underappreciated by the neurosurgery and neuroradiologic communities. This leads to delayed diagnosis, multiple imaging studies, other diagnostic tests, inappropriate surgeries, and repeat office visits. Purpose To evaluate common associations between ISCH and patient demographics/clinical presentation and to analyze the potential for delayed diagnosis. Patient sample Patient sample included those diagnosed with ISCH on imaging at our institution from June 20, 2005 to December 3, 2012. Outcome measures These were based on the patient improvement/stability/decline based on the patients' most recent clinic/office visit when compared with initial presentation. Methods A retrospective search of radiology reports was performed using Illuminate software from June 20, 2005 to December 3, 2012, using the search term “idiopathic spinal cord herniation.” Clinical data were reviewed including patient's age, sex, presenting clinical symptoms, number and type of imaging studies performed as part of the workup, other diagnostic tests, pain procedures, surgeries, and time between original presentation and diagnosis of ISCH on imaging. Results A total of 55 patients had the search term “idiopathic spinal cord herniation” included in their radiology report, of which 37 patients were found to meet the imaging and clinical diagnosis of ISCH. The median time from presentation to imaging diagnosis was 20 months in patients younger than 60 years and 5 months in those 60 years or older (p=.02). Of the 37 patients evaluated, 27 (73%) had no change in symptoms, 5 patients (14%) experienced worsening of symptoms, and 5 (14%) experienced symptom improvement from original presentation to most recent office visit. Among all patients evaluated, three underwent repair of the ventral dural defect in ISCH, resulting in clinical improvement. There was a median of nine outpatient office visits, three magnetic resonance images (MRIs), and one electromyography (EMG) per patient presenting with ISCH. The most frequent complaints were neck/upper back pain in 70%, upper/lower extremity numbness/paresthesias/weakness in 49%, hyperreflexia in 22%, and burning chest pain in 22%. Conclusions Prolonged time to diagnosis and subsequent treatment of ISCH protracts patient symptoms and is associated with redundant diagnostic tests and patient visits. Earlier use of MRI in younger patients (younger than 60 years) may be warranted in those with a clinical presentation suggestive of Brown-Sequard symptomatology. Increasing recognition of ISCH in imaging and surgical communities would lead to improved patient care.

BACKGROUND CONTEXT Creating valid, accurate, and reliable markers of overall survival in patients with cancer would lead to better treatment stratification for this population, whether chemotherapy, radiation, surgery, or palliation. This concept is especially relevant to patients who have spinal metastasis, who will have the lowest rate of survival with stage IV disease. Select patients who undergo surgery for their metastasis may have improved overall survival, neurological outcome, and pain control. However, these procedures are resource intensive, delay the definitive oncologic treatments of chemotherapy and radiotherapy, and potentially morbid, which can erase any survival benefit. Scoring systems have been developed to guide surgical decision making, but validity studies have shown inaccuracies in predicting postoperative morbidity and mortality. New objective measurements of fitness for surgery would have the potential utility to help stratify and aid in the selection of better surgical candidates for spine metastases surgery. One of the hallmarks of human senescence is that of frailty, which has been defined as a decreased reserve to physiologic stressors. Frail patients are known to have increased risk for postoperative morbidity and mortality, but the direct measurement of frailty is impractical. Sarcopenia (lack of muscle mass) has been used successfully as a surrogate for frailty, and a growing body of literature seeks to use sarcopenia to predict outcomes after surgery. PURPOSE In this study, we applied the sarcopenia or frailty paradigm in patients with lung, breast, prostate, or myeloma metastasis to the spine to predict overall survival. Our hypothesis is that sarcopenia can be used as a unique predictor of overall mortality. STUDY DESIGN/SETTING This study was conducted after Institutional Review Board approval (IRB 4370). From an index of patients who have undergone stereotactic body radiation therapy (SBRT) for metastatic spine cancer, we retrospectively identified lung, breast, prostate, or multiple myeloma patients from 2002 to 2012 at our hospital. OUTCOME MEASURES The primary outcome measure was overall survival, which was calculated from the date of the patient's CT scan to date of death or last follow-up. METHODS Using the most recent CT scan available, the total area of each patient's psoas muscle at the L4 vertebral body was measured and recorded. Psoas muscle sizes were divided into tertiles (smallest, middle, and largest) according to average psoas area. Other demographic variables such as age, gender, ethnicity, number of levels, type of cancer, spine surgery, and SBRT target volume were also considered. The median survival time (in days) along with the corresponding 95% confidence interval were computed using Kaplan–Meier estimates for all patients, as well as for the variables of interest. Cox proportional hazards regression analyses were done to estimate the hazard ratios and test for differences in the variables of interest. RESULTS There were 417 patients with spinal metastases from lung cancer, breast cancer, prostate cancer, or multiple myeloma. The average age was 66.3, with equal split of males and females and 52% of patients Caucasian, 40% African American, and 4% other. The median survival for all patients was 173days (95% CI=140–204 days). Patient age, gender, ethnicity, number of levels treated with SBRT, spine surgery done, and SBRT target volume did not affect overall survival. Overall survival was associated with primary tumor histology, with multiple myeloma patients having a significantly longer survival compared to the other three groups (p .77 for all comparisons). Average psoas size significantly predicted overall survival. After multivariate analysis, patients in the 1st tertile (smallest muscle area) for average psoas size had significantly shorter survival as compared to the 3rd tertile (largest muscle area): 115days versus 298, hazard ratio 1.92 (95% CI=1.46–2.53), p CONCLUSIONS Sarcopenia predicts survival in patients with lung cancer, breast cancer, prostate cancer, and multiple myeloma metastases to the spine. Survival prediction was irrespective of cancer histology. This information can assist in patient selection for surgery, as well as to tailor oncologic treatments.