Search

Study Design: cross-sectional survey., Objectives: To evaluate AO Spine members' practices and comfort in managing metastatic and primary spine tumors, explore the use of decision-support and patient assessment tools, and identify knowledge gaps and future needs in spine oncology., Methods: An online survey was distributed to AO Spine members to query comfort levels with key decisions in spinal oncology management, utilization of decision frameworks and spine oncology-specific instruments, and educational material preferences., Results: Responses were obtained from 381 members across 82 countries. Most respondents were orthopedic spine surgeons (62%) or neurosurgeons (36%), with 42% performing 100-200 spine surgeries per year. Extradural primary and metastatic tumors were managed by 84% and 95% of respondents, respectively, with survival and frailty assessment tools used for both. While most surgeons felt comfortable determining when emergency surgery was needed (81% for primary and 82% for metastatic tumors), nuanced decisions about surgical timing were more challenging. Surgeons also noted challenges in tailoring the oncologic surgical plan to what the patient could safely tolerate. There was a strong desire for guidelines on tumor-related spinal pain (85%), treatment timing (85%), stabilization (85%), and glucocorticoid use for symptomatic extradural metastatic tumors (77%). Interest was high for classification systems for spine tumor pain (65%) and stabilization decisions (80%)., Conclusions: Additional support is needed in decision-making regarding surgical timing, patient selection, and tailoring treatment invasiveness to life expectancy and frailty. Surgeons seek further guidance to prevent neurologic deterioration and optimize recovery. Guidelines and classification systems were highly coveted for daily practice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic review., Objectives: The objective of this review paper was to summarize targeted molecular therapy options for spinal chordoma and chondrosarcoma, and to provide an update on the relevant clinical trials open for recruitment., Methods: A systematic review of the current literature was performed, according to PRISMA guidelines, to summarize the latest developments in non-surgical molecular treatment options for low grade malignant primary spinal tumours. We also summarize those actively recruiting clinical trials based on clinicaltrials.gov., Results: A total of 73 studies and completed clinical trials were reviewed. Twenty actively recruiting clinical trials (eight for chordoma and twelve for chondrosarcoma) were identified., Conclusions: There is a strong need to find new therapeutic options to complement surgical resection and radiation therapy, which remain the cornerstone of management. Targeted therapies against molecular pathways show promise as compared to conventional chemotherapy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Delphi study., Objective: The objective of this study was to identify risk factors associated with the development and/or progression of neurological deficits in patients with metastatic spinal disease., Methods: A three-round Delphi study was conducted between January-May 2023 including AO Spine members, comprising mainly neurosurgeons and orthopedic surgeons. In round 1, participants listed radiological factors, patient characteristics, tumor characteristics, previous cancer-related treatment factors and additional factors. In round 2, participants ranked the factors on importance per category and selected a top 9 from all factors. Kendall's W coefficient of concordance was calculated as a measure of consensus. In the final round, participants provided feedback on the rankings resulting from round 2. Lastly, the highest-ranking factors were more clearly defined and operationalized by an expert panel., Results: Over two hundred physicians and researchers participated in each round. The factors listed in the first round were collapsed into 12 radiological factors, 14 patient characteristics, 6 tumor characteristics and 12 previous cancer-related treatment factors. High agreement was found in round 3 on the top-half lists in each category and the overall top 9, originating from round 2. Kendall's W indicated strong agreement between the participants. 'Epidural spinal cord compression', 'aggressive tumor behavior' and 'mechanical instability' were deemed most influential for the development of neurological deficits., Conclusion: This study provides factors that may be related to the development and/or progression of neurological deficits in patients with metastatic spinal disease. This list can serve as a basis for future directions in prognostication research., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Narrative Review., Objective: The management of spinal tumors requires a multi-disciplinary approach including surgery, radiation, and systemic therapy. Surgical approaches typically require posterior segmental instrumentation to maintain long-term spinal stability. Carbon fiber reinforced pedicle screws (CFRP) are increasingly used in the oncologic setting due to reductions in both imaging artifacts and radiotherapy perturbations compared to titanium implants. We performed a review of the literature and highlight advantages and future areas of study for CFRP., Methods: We performed a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 10 articles including 573 patients. Across all studies we reviewed patient demographics, tumor types treated, hardware-related features, complication rates, recurrence, survival, and follow-up., Results: Across 10 studies, a total of 1371 screws placed. Surgical and non-surgical complications were reported in 18.3% of patients. Disease progression at the surgical site was detected in 7.3% of patients. There was no significant difference in clinical or hardware complications between CFRP or titanium implants. The most frequent complication attributable to implanted CFRP hardware included screw breakage in 2.4% and loosening in 1.7% of patients, respectively., Conclusion: CFRP provide a unique tool in the setting of spinal oncology. With a safety profile comparable to titanium, we review the documented advantages of CFRP posterior implants compared to titanium, while also addressing their current limitations. Additionally, we highlight several areas of future research to identify the optimal patients who will achieve the greatest benefit of CFRP., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Narrative review., Objectives: This article aims to provide a narrative review of the current state of research for liquid biopsy in spinal tumors and to discuss the potential application of liquid biopsy in the clinical management of patients with spinal tumors., Methods: A comprehensive review of the literature was performed using PubMed, Google Scholar, Medline, Embase and Cochrane databases, and the review was limited to articles of English language. All the relevant articles which were identified to be related to liquid biomarker study in spinal tumors, were studied in full text., Results: Liquid biopsy has revolutionized the field of precision medicine by guiding personalized clinical management of cancer patients based on the liquid biomarker status. In recent years, more research has been done to investigate its potential utilization in patients with tumors from the spine. Herein, we review the liquid biomarkers that have been proposed in different spine malignancies including chordoma, chondrosarcoma, Ewing sarcoma, osteosarcoma, astrocytoma and ependymoma. We also discuss the wide window of opportunity to utilize these liquid biomarkers in diagnosis, treatment response, monitoring, and detection of minimal residual disease in patients with spinal tumors., Conclusions: Liquid biomarkers, especially blood-derived circulating tumor DNA, has a promising clinical utility as they are disease-specific, minimally invasive, and the procedure is repeatable. Prospective studies with larger populations are needed to fully establish its use in the setting of spinal tumors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Narrative Review., Objective: Contextualized by a narrative review of recent literature, we propose a wound complication prevention and management algorithm for spinal oncology patients. We highlight available strategies and motivate future research to identify optimal and individualized wound management for this population., Methods: We conducted a search of recent studies (2010-2022) using relevant keywords to identify primary literature in support of current strategies for wound complication prevention and management following spine tumor surgery. When primary literature specific to spine tumor cases was not available, data were extrapolated from studies of other spine surgery populations. Results were compiled into a proposed clinical algorithm to guide practice considering available evidence., Results: Based on available literature, we recommend individualized stratification of patients according to identifiable risk factors for wound complication and propose several interventions which might be employed preventatively, including intrawound antibiotic administration, negative pressure wound therapy, and primary flap closure of the surgical wound. Of these, the available evidence, weighing possible risks vs benefits, most strongly favors primary flap closure of surgical wounds, particularly for patients with multiple risk factors. A secondary algorithm to guide management of wound complications is also proposed., Conclusions: Wound complications such as SSI and dehiscence remain a significant source of morbidity following spine tumor surgery. Triaging patients on an individualized basis according to risk factors for complication may aid in selecting appropriate prophylactic strategies to prevent these complications. Future research in this area is still needed to strengthen recommendations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors disclose no financial conflicts of interest directly pertinent to this work. Please see supplemental ICMJE documents for full disclosures.

Study Design: Narrative review of existing literature., Objectives: Significant technological advancements in radiotherapy planning and delivery have enabled new radiotherapy techniques for the management of spine tumors. The objective of this study was to provide a comprehensive summary of these treatment techniques for practicing spine surgeons., Methods: A narrative review of the existing literature on stereotactic body radiation therapy (SBRT) and particle beam therapy (PBT) for the treatment of spine tumors was performed. The characteristics, implementation and evidence supporting these strategies in the management of primary spinal neoplasms were summarized., Results: The clinical effectiveness of SBRT for the control and symptom palliation of metastatic spinal tumors are well demonstrated in multiple clinical trials. Risks such as fracture, radiculopathy and plexopathy exist after spine SBRT, necessitating an individualized approach in a well experienced multidisciplinary setting. SBRT should be considered a key component of a well-rounded treatment plan for metastatic spine tumors in combination with surgery, vertebral augmentation, and drug therapy, where indicated, to achieve optimal patient outcomes. Additionally, PBT and SBRT are also leading to promising results for primary spine tumors, though comparative effectiveness studies and prospective clinical trials are required to establish these modalities more formally as alternatives to conventionally fractionated photon radiotherapy., Conclusions: SBRT and PBT are emerging as effective and well tolerated treatment options for primary and metastatic spine tumors. Additional investigation is needed to personalize these treatment options and further strengthen these approaches as key components in a multidisciplinary approach to the management of spinal neoplasms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AJG reports honoraria from BrainLab; CB reports consulting fees from Depuy-Synthes, Bionaut Labs, Haystack Oncology, Privo Technologies and Galectin Therapeutics, travel support from AO Spine and co-founding and membership to the Board of Advisors for OrisDx and Belay Diagnostics; SB reports consulting fees Nuvasive, travel support from Nuvasive and Stryker and participation in the AO Spine Knowledge Forum; ND reports consulting fees from Stryker, Cerapedics, Baxter and Medtronic, travel support from AO Spine, and stocks/options in Medtronic; CGF reports royalties from Medtronic, consulting fees from Medtronic and Nuvasive, and fellowship support from AO Spine, Depuy and Medtronic; ZLG reports honoraria from AO Foundation and AO Spine Knowledge Forum Tumor, payments for expert testimony from various sources, travel support from AO Spine, participation on the Advisory Board for Proprio, and stocks/options in Lenoss Medical; IL reports royalties from Globus, consulting fees from Depuy Synthes, honoraria from AO Foundation, travel support from AO Foundation, and participation on the Advisory Board for Chiefy; AL reports grants from the European Commission Horizon Europe, Hungarian Academy of Scient, and the National Research, Development and Innovation Fund, royalties from Sanatmetal Ltd., and consulting fees from Inossia Ltd. and Metronic; JR reports consulting fees from Cerapedics, honoraria from Gobus, Depuy Synthes, Cerapedics, travel support from AO Spine, chairing the Advisory Board of Cerapedics, and membership in the Steering Committee of the AO Spine Knowledge Forum Tumor; JJV reports founding and stock ownership of SentryX; LDR reports consulting fees from Icotec and Stryker, honoraria from Icotec and Stryker, and travel support from Icotec and Stryker; AS reports grants from Elekta AB, Varian, Seagen Inc., and BrainLab, consulting fees from Varian, Elekta AB, BrainLab, Merck, AbbVie and Roche, honoraria from AstraZeneca, Elekta AB, Varian, BrainLab, Accuray, and Seagen Inc., Vice Presidency of the International Stereotactic Radiosurgery Society (ISRS), co-chairing the AO Spine Knowledge Forum Tumor, membership and clinical steering committee member of the Elekta MR Linac Research Consortium, chairing the Elekta Oligometastases Group and the Elekta Gamma Knife Icon Group. All other authors declare no conflicts of interest.

Study Design: Narrative Literature review., Objective: To provide a general overview of important molecular markers and targeted therapies for the most common neoplasms (lung, breast, prostate and melanoma) that metastasize to the spine and offer guidance on how to best incorporate them in the clinical setting., Methods: A narrative review of the literature was performed using PubMed, Google Scholar, Medline databases, as well as the histology-specific National Comprehensive Cancer Network guidelines to identify relevant articles limited to the English language. Relevant articles were reviewed for commonly described molecular mutations or targeted therapeutics, as well as associated clinical outcomes, and surgery-related risks., Results: Molecular markers and targeted therapies have dramatically improved the survival of cancer patients. The increasing importance of prognostic molecular markers and targeted therapies provides rationale for their incorporation into clinical decision-making for patients diagnosed with metastatic spine disease. In this review, we discuss the molecular markers/mutations and targeted therapies associated with the most common malignancies that metastasize to the spine and provide a framework that the surgeon can utilize when evaluating patients for potential intervention. Finally, we provide case examples that highlight the importance of molecular prognostication and therapies in surgical decision-making., Conclusion: An integrated understanding of the implications of surgery, radiation, molecular markers and targeted therapies that guide prognostication and treatment is warranted in order to achieve the most favorable outcomes for patients with metastatic spine disease., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic review., Objective: In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries., Methods: Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications., Results: Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation., Conclusion: In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic Review., Objectives: Formalized terminology for pain experienced by spine cancer patients is lacking. The common descriptors of spine cancer pain as mechanical or non-mechanical is not exhaustive. Misdiagnosed spinal pain may lead to ineffective treatment recommendations for cancer patients., Methods: We conducted a systematic review of pain terminology that may be relevant to spinal oncology patients. We provide a comprehensive and unbiased summary of the existing evidence, not limited to the spine surgery literature, and subsequently consolidate these data into a practical, clinically relevant nomenclature for spine oncologists., Results: Our literature search identified 3515 unique citations. Through title and abstract screening, 3407 citations were excluded, resulting in 54 full-text citations for review. Pain in cancer patients is typically described as nociceptive pain (somatic vs visceral), neurologic pain and treatment related pain., Conclusions: We consolidate the terminology used in the literature and consolidated into clinically relevant nomenclature of biologic tumor pain, mechanical pain, radicular pain, neuropathic pain, and treatment related pain. This review helps standardize terminology for cancer-related pain which may help clinicians identify pain generators., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Literature review with clinical recommendation., Objective: A concise curation of the latest spine literature exploring the relationship between expectations and satisfaction for patients with metastatic spinal disease (MSD). Deliver recommendations to practicing clinicians regarding interpretation and utilisation of this evidence., Methods: The latest spine literature in the topic of factors affecting the expectations of patients with MSD was reviewed and clinical recommendations were formulated. Recommendations are graded as strong or Conditional., Results: 5 articles were selected. Article 1: risk factors for the development of dissatisfaction from a cohort of 362 MSD patients. Strong recommendation to incorporate risk factor assessment when considering treatment. Article 2: systematic review assessing the relationship between pre-operative patient expectations and subsequent satisfaction in allied disciplines. Conditional recommendation to optimize patient expectation to positively modify patient satisfaction. Article 3: qualitative study of how clinicians, from different specialties, counsel patients with MSD pre-treatment. Strong recommendation to use a multidisciplinary approach. Article 4 qualitative study of how MSD patients experience their pre-treatment counselling and how that affected their appreciation of treatment success. Conditional recommendation to furnish patients with tailored, expected outcomes in the context of systemic progression. Article 5 Design and validation of a pre-treatment questionnaire specific to MSD. A conditional recommendation to incorporate this questionnaire in clinical and research MSD practice., Conclusion: Patients with MSD are approaching end of life care and high levels of treatment satisfaction are crucial at this juncture. The role of expectation management and comprehensive counselling is critical., Competing Interests: Declaration of Conflicting InterestsThe author(s) received no financial support for the research, authorship, and/or publication of this article. Administrative support was provided by AOSpine. FundingThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was organized by AO Spine through the AO Spine Knowledge Forum Tumor, a focused group of international spine tumor experts. AO Spine is a clinical division of the AO Foundation, which is an independent medically-guided not-for-profit organization. Study support was provided directly through AO Network Clinical Research.

Study Design: A systemic review and a meta-analysis. We also provided a retrospective cohort for validation in this study., Objective: (1) Using a meta-analysis to determine the pooled discriminatory ability of The Skeletal Oncology Research Group (SORG) classical algorithm (CA) and machine learning algorithms (MLA); and (2) test the hypothesis that SORG-CA has less variability in performance than SORG-MLA in non-American validation cohorts as SORG-CA does not incorporates regional-specific variables such as body mass index as input., Methods: After data extraction from the included studies, logit-transformation was applied for extracted AUCs for further analysis. The discriminatory abilities of both algorithms were directly compared by their logit (AUC)s. Further subgroup analysis by region (America vs non-America) was also conducted by comparing the corresponding logit (AUC)., Results: The pooled logit (AUC)s of 90-day SORG-CA was .82 (95% confidence interval [CI], .53-.11), 1-year SORG-CA was 1.11 (95% CI, .74-1.48), 90-day SORG-MLA was 1.36 (95% CI, 1.09-1.63), and 1-year SORG-MLA was 1.57 (95% CI, 1.17-1.98). All the algorithms performed better in United States than in Taiwan ( P < .001). The performance of SORG-CA was less influenced by a non-American cohort than SORG-MLA., Conclusion: These observations might highlight the importance of incorporating region-specific variables into existing models to make them generalizable to racially or geographically distinct regions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective cohort study., Objective: In general, Multiple Myeloma (MM) patients are treated with systemic therapy including chemotherapy. Radiation therapy can have an important supportive role in the palliative management of MM-related osteolytic lesions. Our study aims to investigate the degree of radiation-induced remineralization in MM patients to gain a better understanding of its potential impact on bone mineral density and, consequently, fracture prevention. Our primary outcome measure was percent change in bone mineral density measured in Hounsfield Units (Δ% HU) between pre- and post-radiation measurements, compared to non-targeted vertebrae., Methods: We included 119 patients with MM who underwent radiotherapy of the spine between January 2010 and June 2021 and who had a CT scan of the spine at baseline and between 3-24 months after radiation. A linear mixed effect model tested any differences in remineralization rate per month (β difference ) between targeted and non-targeted vertebrae., Results: Analyses of CT scans yielded 565 unique vertebrae (366 targeted and 199 non-targeted vertebrae). In both targeted and non-targeted vertebrae, there was an increase in bone density per month (β overall = .04; P = .002) with the largest effect being between 9-18 months post-radiation. Radiation did not cause a greater increase in bone density per month compared to non-targeted vertebrae (β difference = .67; P = .118)., Conclusion: Our results demonstrate that following radiation, bone density increased over time for both targeted and non-targeted vertebrae. However, no conclusive evidence was found that targeted vertebrae have a higher remineralization rate than non-targeted vertebrae in patients with MM., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Systematic review and meta-analysis., Objectives: To evaluate the accuracy of placement for cervical pedicle screws with and without the use of spinal navigation., Methods: A structured search was conducted in electronic databases without any language or date restrictions. Eligible studies reported the proportion of accurately placed cervical pedicle screws measured on intraoperative or postoperative 3D imaging, and reported whether intraoperative navigation was used during screw placement. Randomized Studies (MINORS) criteria were used to evaluate the methodological quality of how accuracy was assessed for cervical pedicle screws., Results: After screening and critical appraisal, 4697 cervical pedicle screws from 18 studies were included in the meta-analysis. The pooled proportion for cervical pedicle screws with a breach up to 2 mm was 94% for navigated screws and did not differ from the pooled proportion for non-navigated screws (96%). The pooled proportion for cervical pedicle screws placed completely in the pedicle was 76% for navigated screws and did not differ from the pooled proportion for non-navigated screws (82%). Intraoperative screw reposition rates and screw revision rates as a result of postoperative imaging also did not differ between navigated and non-navigated screw placement., Conclusions: This systematic review and meta-analysis found that the use of spinal navigation systems does not significantly improve the accuracy of placement of cervical pedicle screws compared to screws placed without navigation. Future studies evaluating intraoperative navigation for cervical pedicle screw placement should focus on the learning curve, postoperative complications, and the complexity of surgical cases., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: B.J.J.B., M.L.J., and J.J.V. collaborate with Philips Medical, Best, the Netherlands, although they were not involved in the conducted research.

Study Design: Retrospective cohort study., Objectives: Up to 30% of Multiple Myeloma (MM) patients are expected to experience Epidural Spinal Cord Compression (ESCC) during the course of their disease. To prevent irreversible neurological damage, timely diagnosis and treatment are important. However, debate remains regarding the optimal treatment regimen. The aim of this study was to investigate the neurological outcomes and frequency of retreatments for MM patients undergoing isolated radiotherapy and surgical interventions for high-grade (grade 2-3) ESCC., Methods: This study included patients with MM and high-grade ESCC treated with isolated radiotherapy or surgery. Pre- and post-treatment American Spinal Injury Association (ASIA) impairment scale and retreatment rate were compared between the 2 groups. Adjusted multivariable logistic regression was utilized to examine differences in neurologic compromise, pain, and retreatments., Results: A total of 247 patients were included (Radiotherapy: n = 154; Surgery: n = 93). After radiotherapy, 82 patients (53%) achieved full neurologic function (ASIA E) at the end of follow-up. Of the surgically treated patients, 67 (64%) achieved full neurologic function. In adjusted analyses, patients treated with surgery were less likely to experience neurologic deterioration within 2 years (OR = .15; 95%CI .05-.44; P = .001) and had less pain (OR = .29; 95%CI .11-.74; P = .010). Surgical treatment was not associated with an increased risk of retreatments (OR = .64; 95%CI .28-1.47; P = .29) or death (HR = .62, 95%CI .28-1.38; P = .24)., Conclusions: After adjusting for baseline differences, surgically treated patients with high-grade ESCC showed better neurologic outcomes compared to patients treated with radiotherapy. There were no differences in risk of retreatment or death., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective cohort study., Objectives: Minimizing delays in referral, diagnosis and treatment of patients with symptomatic spinal metastases is important for optimal treatment outcomes. The primary objective of this study was to investigate several forms of delay from the onset of symptoms until surgical treatment of spinal metastases for patients with and without a known preexisting known malignancy., Methods: All patients receiving surgical treatment for spinal metastases in a single tertiary spine center were identified. Referral patterns were reconstructed and the total delay was divided into 4 categories: patient delay (onset of symptoms until medical consultation), diagnostic delay (medical consultation until diagnosis), referral delay (diagnosis until referral to spine surgeon) and treatment delay (referral spine to surgeon until treatment). These intervals were compared between patients with and without a known preexisting malignancy., Results: The median total delay was 99 days, patient delay 19 days, diagnostic delay 21,5 days, referral delay 7 days, treatment delay 8 days and diagnosis and treatment delay combined 18,5 days. No difference in total delay was observed between patients with and without a known preexisting malignancy. Total delay was not significantly associated with patient age, sex, oncological history, tumor prognosis and spinal level of the tumor., Conclusions: Patients with symptomatic spinal metastases experience considerable delays, even after metastatic spinal disease has been diagnosed, regardless of a preexisting malignancy. By identifying and eliminating the causes of these delays, diagnosis, referral and treatment may be expedited leading to improved patient outcome.

Study Design: Retrospective cohort study., Objectives: Symptoms caused by spinal metastases are often difficult to distinguish from symptoms caused by non-malignant spinal disease, complicating timely diagnosis, referral and treatment. The ensuing delays may promote the risk of neurological deficits or severe mechanical instability and consequent emergency surgery, leading to poorer prognosis. Presumably, treatment delay may subsequently lead to more health-care consumption and therefore increased average costs of treatment., Methods: All patients surgically treated for spinal metastases were included in the current study. Based on the presence of alarming symptoms and urgency of the required intervention, patients were categorized as having received timely or delayed treatment. Pre-surgical, in-hospital, aftercare and total costs were analyzed and compared between the 2 groups., Results: In total, 299 patients were included, of which 205 underwent timely and 94 delayed treatment. There was no significant difference in pre-surigcal costs (€3.229,13 in the timely treated group vs. €2.528,70 in the delayed treatment group, p = 0.849). The in-hospital costs (€16.738,49 vs. €13.108,81, p < 0.001) and the aftercare costs (€13.950,37 vs . 3.981,93, p < 0.001) were significantly higher for delayed treatment vs. timely treatment, respectively. The total costs were €33.741,71 for delayed treatment and €20.318,52 for timely treatment (p < 0.001)., Conclusions: The total costs for timely treated patients with spinal metastases are significantly lower compared with patients receiving delayed treatment. Investing in the optimization of referral patterns may therefore reduce the overall pretreatment delay and subsequently increase patient outcome, leading to better clinical outcomes at lower costs.

Study Design: Literature review., Objective: To provide an overview of the recent advances in spinal oncology, emphasizing the key role of the surgeon in the treatment of patients with spinal metastatic tumors., Methods: Literature review., Results: Therapeutic advances led to longer survival times among cancer patients, placing significant emphasis on durable local control, optimization of quality of life, and daily function for patients with spinal metastatic tumors. Recent integration of modern diagnostic tools, precision oncologic treatment, and widespread use of new technologies has transformed the treatment of spinal metastases. Currently, multidisciplinary spinal oncology teams include spinal surgeons, radiation and medical oncologists, pain and rehabilitation specialists, and interventional radiologists. Consistent use of common language facilitates communication, definition of treatment indications and outcomes, alongside comparative clinical research. The main parameters used to characterize patients with spinal metastases include functional status and health-related quality of life, the spinal instability neoplastic score, the epidural spinal cord compression scale, tumor histology, and genomic profile., Conclusions: Stereotactic body radiotherapy revolutionized spinal oncology through delivery of durable local tumor control regardless of tumor histology. Currently, the major surgical indications include mechanical instability and high-grade spinal cord compression, when applicable, with surgery providing notable improvement in the quality of life and functional status for appropriately selected patients. Surgical trends include less invasive surgery with emphasis on durable local control and spinal stabilization., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Boriani reports educational commitments with K2M and Nuvasive, which are outside the submitted work. Dr Fisher reports consulting and royalties from Medtronic; research grants from OREF; and fellowship support paid to institution from AOSpine and Medtronic, which are all outside the submitted work. Dr Sahgal reports past educational seminars with Elekta AB, Accuray Inc, and Varian medical systems; research grant with Elekta AB; travel accommodations and expenses from Elekta and Varian; and belongs to the Elekta MR Linac Research Consortium. Dr Gokaslan reports research support from AOSpine North America and stock ownership of Spinal Kinetics, which are all outside the submitted work. Dr Rhines reports educational commitments with Stryker, which are outside the submitted work. Dr Laufer reports receiving consulting fees from Globus, Depuy/Synthes, and SpineWave.

Study Design: Systematic review., Objectives: Sacral chordomas are rare, primary tumors of the spine, best treated with en bloc resection. The purpose of this study was to assess the literature for resected sacral chordoma and to quantify the prevalence of, risk factors for, and treatment outcomes of local and distant recurrence therein., Methods: We searched 5 online databases from January 1980 to May 2016 to find articles that report survival, recurrence outcomes, and/or prognostic factors for the resected sacral chordoma patient population. Characteristics and clinical outcomes of the pooled cohort are reported. Fisher exact tests, unpaired t tests, and one-way analysis of variance were used to investigate patient- and treatment-associated prognostic factors for local and distant recurrence. Survival analyses were performed for time to local recurrence and death. The protocol's PROSPERO ID is CRD42015024384., Results: Fifty-seven studies, with 1235 unique sacral chordoma patients, were included in this review. Local and distant recurrence occurred in 42.6% and 22.4% of patients with adequate follow-up, respectively. Kaplan-Meier overall median survival for patients with and without recurrence were 98 and 209 months after surgery, respectively. Wide surgical margin was associated with a lower rate of local recurrence; and wide surgical margin, female sex, and patient age ≥65 years were associated with lower rates of distant recurrence., Conclusions: While surgical margin remains the most significant prognostic factor for local and distant recurrence, combined surgical approach may be associated with local recurrence. Male sex and age <65 years may be associated with distant recurrence. Patients with risk factors for recurrence should undergo close monitoring to maximize survival., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Rory Goodwin: UNCF Merck Postdoctoral Fellow and has received an award from the Burroughs Wellcome Fund. Daniel Kerekes: None. A. Karim Ahmed: Has received an award from the NREF Medical Student Summer Research Fellowship. Jorrit-Jan Verlaan: None. Chetan Bettegowda: None. Nancy Abu-Bonsrah: None. Daniel M. Sciubba: Consultant for Medtronic, Globus, DePuy, Styrker, and Orthofix.