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Hybrid therapy, consisting of separation surgery followed by stereotactic body radiation therapy, has become the mainstay treatment for radioresistant spinal metastases. Histology-specific outcomes for hybrid therapy are scarce. In clinical practice, colorectal cancer (CRC) is particularly thought to have poor outcomes regarding spinal metastases. The goal of this study was to evaluate clinical outcomes for patients treated with hybrid therapy for spinal metastases from CRC.This retrospective study was performed at a tertiary cancer center. Adult patients with CRC spinal metastasis who were treated with hybrid therapy for high-grade epidural spinal cord or nerve root compression from 2005 to 2020 were included. Outcome variables evaluated included patient demographics, overall survival and progression-free survival, surgical and radiation complications, and clinical-genomic correlations.Inclusion criteria were met by 50 patients. Progression of disease occurred in 7 (14%) patients at the index level, requiring reoperation and/or reirradiation at a mean of 400 days after surgery. Postoperative complications occurred in 16% of patients, with 3 (6%) requiring intervention. APC exon 14 and 16 mutations were found in 15 of 17 patients tested and in all 3 of 7 local failures tested. Twenty patients (40%) underwent further radiation due to disease progression at other spinal levels.Hybrid therapy in patients with CRC resulted in 86.7% local control at 2 years after surgery, with limited complications. APC mutations are commonly present in CRC patients with spine metastases and may suggest worse prognosis. Patients with CRC spinal metastases commonly progress outside the index treatment level.

In treatment of metastatic epidural spinal cord compression (MESCC), hybrid therapy, consisting of separation surgery, followed by stereotactic body radiation therapy, has become the mainstay of treatment for radioresistant pathologies, such as non-small-cell lung cancer (NSCLC).To evaluate clinical outcomes of MESCC secondary to NSCLC treated with hybrid therapy and to identify clinical and molecular prognostic predictors.This is a single-center, retrospective study. Adult patients (≥18 years old) with pathologically confirmed NSCLC and spinal metastasis who were treated with hybrid therapy for high-grade MESCC or nerve root compression from 2012 to 2019 are included. Outcome variables evaluated included overall survival (OS) and progression-free survival, local tumor control in the competing risks setting, surgical and radiation complications, and clinical-genomic correlations.One hundred and three patients met inclusion criteria. The median OS for this cohort was 6.5 months, with progression of disease noted in 5 (5%) patients at the index tumor level requiring reoperation and/or reirradiation at a mean of 802 days after postoperative stereotactic body radiation therapy. The 2-year local control rate was 94.6% (95% CI: 89.8-99.3). Epidermal growth factor receptor (EGFR) treatment-naïve patients who initiated EGFR-targeted therapy after hybrid therapy had significantly longer OS (hazard ratio 0.47, 95% CI 0.23-0.95, P = .04) even after adjusting for smoking status. The presence of EGFR exon 21 mutation was predictive of improved progression-free survival.Hybrid therapy in NSCLC resulted in 95% local control at 2 years after surgery. EGFR treatment-naïve patients initiating therapy after hybrid therapy had significantly improved survival advantage. EGFR-targeted therapy initiated before hybrid therapy did not confer survival benefit.

Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life.The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery.A retrospective review was conducted at five large tertiary centers in the United States and Taiwan.The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions.The primary outcome was 6-week mortality.Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application.The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.

Central tendency analysis studies demonstrate that surgery provides pain relief in spinal metastatic tumors. However, they preclude patient-specific probability of treatment outcome.To use responder analysis to study the variability of pain improvement.In this single-center, retrospective analysis, 174 patients were studied. Logistic regression modeling was used to associate preoperative characteristics with rating the Brief Pain Inventory (BPI) worst pain item 0 to 4. Linear regression modeling was used to associate preoperative characteristics with minimal clinically important improvement (MCI) in physical functioning defined by a 1-point decrease in the BPI Interference Construct score from preoperative baseline to 6 months postoperatively.Patient-level analysis revealed that 60% of patients experienced an improvement in pain. At least half experienced a decrease in pain resulting in MCI in physical functioning. Cutpoint analysis revealed that 48% were responders. Increasing scores on the preoperative pain intensity BPI items, the MD Anderson Symptom Inventory (MDASI) Core Symptom Severity Construct, the MDASI Spine Tumor-Specific Construct, the presence of preoperative neurologic deficits, and postoperative complications were associated with lower probability of treatment success while increasing severity in all BPI pain items, and MDASI constructs were associated with increased probability of MCI in physical function. Significant mortality and loss to follow-up intrinsic to this patient population limit the strength of these data.Although patients with milder preoperative symptoms are likely to achieve better pain relief after surgery, patients with worse preoperative symptom also benefit from surgery with adequate pain relief with an improvement in physical function.

Background The role of tumor genomic profiling is rapidly growing as it results in targeted, personalized, cancer therapy. Though routinely used in clinical practice, there are no data exploring the reliability of genomic data obtained from spine metastases samples often leading to multiple biopsies in clinical practice. This study compares the genomic tumor landscape between spinal metastases and the corresponding primary tumors as well as between spinal metastases and visceral metastases. Methods Spine tumor samples, obtained for routine clinical care from 2013 to 2019, were analyzed using MSK-IMPACT, a next-generation sequencing assay. These samples were matched to primary or metastatic tumors from the corresponding patients. A concordance rate for genomic alterations was calculated for matching sample pairs within patients for the primary and spinal metastatic tumor samples as well as for the matching sample pairs within patients for the spinal and visceral metastases. For a more robust and clinically relevant estimate of concordance, subgroup analyses of previously established driver mutations specific to the main primary tumor histologies were performed. Results Eighty-four patients contributed next-generation sequencing data from a spinal metastasis and at least one other site of disease: 54 from the primary tumor, 39 had genomic tumor data from another, nonspinal metastasis, 12 patients participated in both subsets. For the cohort of matched primary tumors and spinal metastases (n = 54) comprised of mixed histologies, we found an average concordance rate of 96.97% for all genetic events, 97.17% for mutations, 100% for fusions, 89.81% for deletions, and 97.01% for amplifications across all matched samples. Notably, >25% of patients harbored at least one genetic variant between samples tested, though not specifically for known driver mutations. The average concordance rate of driver mutations was 96.99% for prostate cancer, 95.69% (P = .0004513) for lung cancer, and 96.43% for breast cancer. An average concordance of 99.02% was calculated for all genetic events between spine metastases and non-spinal metastases (n = 41) and, more specifically, a concordance rate of 98.91% was calculated between spine metastases and liver metastases (n = 12) which was the largest represented group of nonspine metastases. Conclusion Sequencing data performed on spine tumor samples demonstrate a high concordance rate for genetic alterations between the primary tumor and spinal metastasis as well as between spinal metastases and other, visceral metastases, particularly for driver mutations. Spine tumor samples may be reliably used for genomic-based decision making in cancer care, particularly for prostate, NSCLC, and breast cancer.

The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. Although titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose perturbation in postoperative radiation therapy and have shown biostability and biocompatibility that are comparable to titanium implants. Using the PubMed and Web of Sciences databases, we conducted a systematic review of carbon-based screw and rod fixation systems in the treatment of spinal tumors. We reviewed clinical studies regarding safety of spine fixation with carbon fiber-reinforced (CFR) implants and biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-polyether ether ketone implants has the potential to benefit patients with spine tumor. Clinical studies have shown no increase in complications with implementation of CFR-polyether ether ketone implants, and these devices seem to have sufficient stiffness and pullout strength. However, further trials are necessary to determine if there is a clinically significant impact on local tumor control.

BACKGROUND: Historically, symptomatic, benign intradural extramedullary (IDEM) spine tumors have been managed with surgical resection. However, minimal robust data regarding patient-reported outcomes (PROs) following treatment of symptomatic lesions exists. Moreover, there are increasing reports of radiosurgical management of these lesions without robust health-related quality of life data. OBJECTIVE: To prospectively analyze PROs among patients with benign IDEM spine tumors undergoing surgical resection to define the symptomatic efficacy of surgery. METHODS: Prospective, single-center observational cohort study of patients with benign IDEM spine tumors undergoing open surgical resection. Pre- and postoperative Brief Pain Index (BPI) and MD Anderson Symptom Inventory (MDASI) questionnaires were used to quantitatively assess their symptom control after surgical intervention. Matched pairs were analyzed with the Wilcoxon signed-rank test. RESULTS: A total of 57 patients met inclusion criteria with both pre- and postoperative PROs. There were 35 schwannomas, 18 meningiomas, 2 neurofibromas, 1 paraganglioma, and 1 mixed schwannoma/neurofibroma. Most patients were American Spinal Injury Association Impairment (ASIA) E (93%) with high-grade spinal cord compression (77%), and underwent either a 2 or 3 level laminectomy (84%). Surgical resection resulted in statistically significant improvement in all 3 composite BPI constructs of pain-severity, pain-interference, and overall patient pain experience (P

Background Over the last 2 decades, advances in systemic therapy have increased the expected overall survival for patients with cancer. It is unclear whether the same survival benefit has been conferred to patients requiring surgery for metastatic spinal disease. Objective To examine trends in postoperative survival over a 20-yr period for patients surgically treated for spinal metastatic disease. Methods Data were obtained for 1515 patients who underwent surgery for metastatic epidural spinal cord compression or tumor-related mechanical instability. Postoperative overall survival was calculated for all included patients using Kaplan-Meier methodology from date of surgery until death or last follow-up for those who were censored. Trends were analyzed using Cox proportional hazards modeling. Results Patients with renal, breast, lung, and colon cancers experienced a statistically significant improvement in survival over time based on the year of surgery (40%-100% improvement over the study period), whereas the overall survival trend for the entire cohort did not reach statistical significance (P = .12, median survival 0.71 yr, 95% CI 0.63-0.78). Patients presenting with synchronous metastatic disease had better survival compared to those presenting with metachronous disease (median overall survival: 0.94 vs 0.63 yr, respectively; log-rank P-value = .00001). Conclusion The postoperative survival among patients with spinal metastases has improved over the past 20 yr, particularly in patients with kidney, breast, lung, and colon tumors metastatic to the spine. The observed survival improvement emphasizes the need for long-term outcome consideration in treatment decisions for patients undergoing surgery for spinal metastatic tumors.

Study Design:Literature review.Objective:To provide an overview of the recent advances in minimal access surgery (MAS) for spinal metastases.Methods:Literature review.Results:Experience gained from MAS in the trauma, degenerative and deformity settings has paved the road for MAS techniques for spinal cancer. Current MAS techniques for the treatment of spinal metastases include percutaneous instrumentation, mini-open approaches for decompression and tumor resection with or without tubular/expandable retractors and thoracoscopy/endoscopy. Cancer care requires a multidisciplinary effort and adherence to treatment algorithms facilitates decision making, ultimately improving patient outcomes. Specific algorithms exist to help guide decisions for MAS for extradural spinal metastases. One major paradigm shift has been the implementation of percutaneous stabilization for treatment of neoplastic spinal instability. Percutaneous stabilization can be enhanced with cement augmentation for increased durability and pain palliation. Unlike osteoporotic fractures, kyphoplasty and vertebroplasty are known to be effective therapies for symptomatic pathologic compression fractures as supported by high level evidence. The integration of systemic body radiation therapy for spinal metastases has eliminated the need for aggressive tumor resection allowing implementation of MAS epidural tumor decompression via tubular or expandable retractors and preliminary data exist regarding laser interstitial thermal therapy and radiofrequency ablation for tumor control. Neuronavigation and robotic systems offer increased precision, facilitating the role of MAS for spinal metastases.Conclusions:MAS has a significant role in the treatment of spinal metastases. This review highlights the current utilization of minimally invasive surgical strategies for treatment of spinal metastases.

The management of spinal metastatic renal cell carcinoma (mRCC) is controversial regarding extent of resection and radiation dosing. OBJECTIVE: To determine outcomes in patients treated with hybrid therapy (separation surgery plus adjuvant stereotactic body radiation therapy [SBRT]) for mRCC. METHODS: A retrospective study of a prospectively collected cohort of patients undergoing hybrid therapy for mRCC between 2003 and 2017 was performed. SBRT was delivered as high-dose single-fraction, high-dose hypofractionated, or low-dose hypofractionated. Extent of disease, clinical and operative outcomes, and complications data were collected, and associations with overall survival (OS) and progression-free survival were determined. RESULTS: Ninety patients with mRCC with high-grade epidural spinal cord compression (ESCC grades 2 and 3) were treated. Metastases were widespread, oligometastatic, and solitary in 56%, 33%, and 11% of patients, respectively. SBRT delivered was high-dose single-fraction, high-dose hypofractionated, and low-dose hypofractionated in 24%, 56%, and 20% of patients, respectively. The 1-yr cumulative incidence of major complications was 3.4% (95% confidence interval [CI]: 0.0%-7.2%). The median follow-up was 14.2 mo for the entire cohort and 38.3 mo for survivors. The 1-yr cumulative incidence of progression was 4.6% (95% CI: 0.2%-9.0%), which translates to a local control rate of 95.4% (95% CI: 91.0%-99.8%) 1 yr after surgery. The median OS for the cohort was 14.8 mo. CONCLUSION: These data support the use of hybrid therapy as a safe and effective strategy for the treatment of renal cell spine metastases.

OBJECTIVE: Dedifferentiated chordomas (DC) are genetically and clinically distinct from conventional chordomas (CC), exhibiting frequent SMARCB1 alterations and a more aggressive clinical course. We compared treatment and outcomes of DC and CC patients in a retrospective cohort study from a single, large-volume cancer center. METHODS: Overall, 11 DC patients were identified from 1994 to 2017 along with a cohort of 68 historical control patients with CC treated during the same time frame. Clinical variables and outcomes were collected from the medical record and Wilcoxon rank sum or Fisher exact tests were used to make comparisons between the two groups. Kaplan–Meier survival analysis and log-rank tests were used to compare DC and CC overall survival. RESULTS: DC demonstrated a bimodal age distribution at presentation (36% age 0–24; 64% age > 50). DC patients more commonly presented with metastatic disease than CC patients (36% vs. 3% p = 0.000). DC patients had significantly shorter time to local treatment failure after radiation therapy (11.1 months vs. 34.1 months, p = 0.000). The rate of distant metastasis following treatment was significantly higher in DC compared to CC (57% vs. 5%, p = 0.000). The median overall survival after diagnosis for DC was 20 months (95% CI 0–48 months) compared to 155 months (95% CI 94–216 months) for CC (p = 0.007). CONCLUSION: DC patients exhibit significantly higher rates of both synchronous and metachronous metastases, as well as shorter overall survival rates compared to conventional chordoma. The relatively poor survival outcomes with conventional therapies indicate the need to study targeted therapies for the treatment of DC.

Beginning with basic stereotactic operative methods in neurosurgery, intraoperative navigation and image guidance systems have since become the norm in that field. Following the introduction of image guidance into spinal surgery, there has been a dramatic increase in its utilization across disciplines and pathologies. Spine tumor surgery encompasses a wide range of complex surgical techniques and treatment strategies. Similarly to deformity correction and trauma surgery, spine navigation holds potential to improve outcomes and optimize surgical technique for spinal tumors. Recent data demonstrate the applicability of neuro-navigation in the field of spinal oncology, particularly for spinal stabilization, maximizing extent of resection and integration of minimally invasive therapies. The rapid introduction of new, less invasive, and ablative surgical techniques in spine oncology coupled with the rising incidence of spinal metastatic disease make it imperative for spine surgeons to be familiar with the indications for and limitations of imaging guidance. Herein, we provide a practical, current concepts narrative review on the use of spinal navigation in three areas of spinal oncology: (a) extent of tumor resection, (b) spinal column stabilization, and (c) focal ablation techniques.

BACKGROUND: Minimal access surgery (MAS) allows early return to systemic and radiation therapy in patients with cancer leading to its increasing utilization in the treatment of spinal metastases. Systematic examination of surgical indications resulted in the development of an algorithm for implementation of MAS in the treatment of spinal metastases. The object of this study was to evaluate a spine tumor MAS treatment algorithm using patient-reported outcomes in cancer patients undergoing treatment of spinal metastases. METHODS: A prospective cohort study. Patients who underwent spinal percutaneous instrumented stabilization with the addition of MAS cord or nerve root decompression and/or kyphoplasty when indicated at a tertiary cancer center between December 2013 and August 2016 were included. Validated patient reported outcome (PRO) measures including the Brief Pain Inventory (BPI) and the MD Anderson Symptom Inventory – Spine module (MDASI-sp) were utilized. PROs were collected and compared at baseline, 3 month and long-term follow up (4.5–12 months). RESULTS: Fifty-one patients were included. MAS resulted in a statistically significant decrease in the severity of pain, and improved activity, ability to work and enjoyment of life (P

Background Conventional external beam radiation and stereotactic radiosurgery are common radiation techniques used to treat spinal tumors. Intraoperative brachytherapy (BT) may serve as an alternative when other options have been exhausted or as an adjunct in combination with other therapies. The objective of this study was to systematically review the literature on BT use in spinal tumor surgery. Methods PubMed and Embase databases were systematically queried for literature reporting the use of BT in the surgical treatment of spinal tumors. PRISMA guidelines were followed. A meta-analysis was performed. Results Of the 203 initial articles queried, 15 studies were included. Of the 370 total patients described, 78% were treated for spine metastases. Indications for BT included tumors refractory to previous treatments and inability to tolerate chemotherapy, radiation, and/or open surgery. Seed placement was the most common method of delivery (58%) compared with plaques (42%). BT was placed during an open procedure in 52%, and of the remaining percutaneous procedures, 47% were combined with cement augmentation. Tumor recurrence rates varied from 13% to 49%. Seven studies reporting visual analog scale scores reported significant improvement in pain control. Conclusions BT was used to treat metastatic disease in patients who failed previous therapies and could not tolerate open surgery or further therapy. This review summarizes the major findings in the available literature pertaining to patient background, indications, and outcomes. Spinal BT seems to be a viable option for spine tumor treatment and should be made available at treating centers.

The combination of separation surgery and stereotactic body radiotherapy optimizes the treatment of metastatic spine tumors. The integration of SBRT into treatment paradigms produces superb local control rates and consequently has diminished the role of surgery from principle treatment to one of adjuvant therapy. Under this paradigm, hybrid therapy for the treatment of metastatic spine tumors employs separation surgery to decompress the spinal cord and stabilize the spine while creating a safe target for ablative SBRT. Hybrid therapy is well tolerated, allows an early return to systemic therapy, and provides durable, local tumor control compared with more aggressive traditional approaches.

Intramedullary spinal cord tumors (IMSCT) comprise a rare subset of CNS tumors that have distinct management strategies based on histopathology. These tumors often present challenges in regards to optimal timing for surgery, invasiveness, and recurrence. Advances in microsurgical techniques and technological adjuncts have improved extent of resection and outcomes with IMSCT. Furthermore, adjuvant therapies including targeted immunotherapies and image-guided radiation therapy have witnessed rapid development over the past decade, further improving survival for many of these patients. In this review, we provide an overview of types, epidemiology, imaging characteristics, surgical management strategies, and future areas of research for IMSCT.

The incidence of metastatic spinal disease is increasing as systemic treatment options are improving and concurrently increasing the life expectancy of patients, and the interventions are becoming increasingly complex. Treatment decisions are also complicated by the increasing armamentarium of surgical treatment options. Decision-making frameworks such as NOMS (neurologic, oncologic, mechanical, and systemic) help guide practitioners in their decision making and provide a structure that would be readily adaptable to the evolving landscape of systemic, surgical, and radiation treatments. This article describes these decision-making frameworks, discusses their relative benefits and shortcomings, and details our approach to treating these complex patients.

Background Resection of large nerve sheath tumors in the lumbar spine using minimally invasive approaches is challenging, as approaches to tumors in this region may require facetectomy or partial resection of adjacent ribs for access to the involved neuroforamen and instrumentation across the involved joint to prevent subsequent kyphotic deformity. Objective To describe a robot-assisted retroperitoneal approach for resection of a lumbar nerve sheath tumor, obviating the need for facetectomy and instrumentation. The operation is described, together with intraoperative images and an annotated video, in the context of a schwannoma arising from the right L1 root. Methods The operation was performed by a urologic surgeon and a neurosurgeon. The patient was placed in lateral position, and the da Vinci Xi robot was used for retroperitoneal access via 5 ports along the right flank. Ultrasound was used to localize the tumor within the psoas. The tumor capsule was defined and released. Encountered nerves were stimulated, allowing small sensory nerves to be identified and safely divided. The tumor was traced into the right L1-L2 neuroforamen and removed. Results Complete en bloc resection of the tumor was achieved, including the paraspinal and foraminal components, without any removal of bone and without violation of the dura. Conclusion In selected patients, a robot-assisted retroperitoneal approach represents a minimally invasive alternative to traditional approaches for resection of lumbar nerve sheath tumors. This approach obviates the need for bone removal and instrumented spinal fusion. Interdisciplinary collaboration, as well as use of adjunctive technologies, including intraoperative ultrasound and neurophysiologic monitoring, is advised.

BACKGROUND CONTEXT The SORG machine-learning algorithms were previously developed for preoperative prediction of overall survival in spinal metastatic disease. On sub-group analysis of a previous external validation, these algorithms were found to have diminished performance on patients treated after 2010. PURPOSE The purpose of this study was to assess the performance of these algorithms on a large contemporary cohort of consecutive spinal metastatic disease patients. STUDY DESIGN/SETTING Retrospective study performed at a tertiary care referral center. PATIENT SAMPLE Patients of 18 years and older treated with surgery for metastatic spinal disease between 2014 and 2016. OUTCOME MEASURES Ninety-day and one-year mortality. METHODS Baseline patient and tumor characteristics of the validation cohort were compared to the development cohort using bivariate logistic regression. Performance of the SORG algorithms on external validation in the contemporary cohort was assessed with discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score compared to the null-model Brier score), and decision curve analysis. RESULTS Overall, 200 patients were included with 90-day and 1-year mortality rates of 55 (27.6%) and 124 (62.9%), respectively. The contemporary external validation cohort and the developmental cohort differed significantly on primary tumor histology, presence of visceral metastases, American Spinal Injury Association impairment scale, and preoperative laboratory values. The SORG algorithms for 90-day and 1-year mortality retained good discriminative ability (c-statistic of 0.81 [95% confidence interval [CI], 0.74–0.87] and 0.84 [95% CI, 0.77–0.89]), overall performance, and decision curve analysis. The algorithm for 90-day mortality showed almost perfect calibration reflected in an overall calibration intercept of −0.07 (95% CI: −0.50, 0.35). The 1-year mortality algorithm underestimated mortality mainly for the lowest predicted probabilities with an overall intercept of 0.57 (95% CI: 0.18, 0.96). CONCLUSIONS The SORG algorithms for survival in spinal metastatic disease generalized well to a contemporary cohort of consecutively treated patients from an external institutional. Further validation in international cohorts and large, prospective multi-institutional trials is required to confirm or refute the findings presented here. The open-access algorithms are available here: https://sorg-apps.shinyapps.io/spinemetssurvival/ .

Surgical decompression and stabilization followed by radiosurgery represents an effective method for local tumor control and neurologic preservation for patients with metastatic epidural spinal cord compression (MESCC). We have previously demonstrated improvement in health-related quality of life (HrQOL) after this combined modality treatment ("hybrid therapy").The current analysis focuses on delineation of patient-specific prognostic factors predictive of HrQOL change after combined surgery-stereotactic radiosurgery (SRS) treatment of MESCC.This is a prospective, single-center, cohort study.One hundred and eleven patients with MESCC who underwent separation surgery followed by SRS were included.Prognostic factors associated with improved patient-reported outcome (PRO) measures.Patient-reported outcome tools, that is, Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory-Spine Tumor (MDASI-SP), both validated in the cancer population, were prospectively collected. Numeric prognostic factors were correlated with PRO measures using the Spearman rank correlation coefficient. Categorical prognostic factors were correlated with PRO measures using the Wilcoxon two-sample test (for two categories) or the Kruskal-Wallis test (for three or more categories). All statistical tests were two-sided with a level of significance.05 for correlation of prognostic factors with PRO constructs and a level of significance.0014 for correlation of prognostic factors with PRO items. Statistical analyses were done in SAS (version 9.4, Cary, NC, USA).One hundred and eleven patients were included in this analysis. Patients with lower preoperative Medical Research Council (MRC) motor scores experienced a greater decrease in symptom interference (BPI interference construct (p=.03) and individual functional measures including general activity (p=.001), walking (p=.001), and normal work (p=.006)). Lumbar location was associated with better outcomes than cervical or thoracic as noted on the BPI pain experience construct (p=.03) and MDASI-SP interference (p=.01) and core symptom (p=.002) constructs. Patients with American Spinal Injury Association (ASIA) scores of C or D benefit more than those with ASIA E on BPI interference construct (p=.04). Patients with higher Eastern Cooperative Oncology Group (ECOG) scores at presentation benefit more than those with low ECOG scores on MDASI-SP interference construct (p=.03). Women benefit more than men on BPI interference (p=.03) and pain experience (p=.04) constructs. Patients with prior spinal surgery at the current level of interest benefit less than those who are naïve surgical patients in MDASI-SP interference construct (p=.04).Delineation of patient characteristics associated with HrQOL improvement provides crucial information for patient selection, patient education, and setting treatment expectations. For patients with MESCC treated with hybrid therapy using surgery and radiosurgery, the presence of neurologic deficits and diminished performance status, lumbar tumor level, and female gender were associated with greater PRO improvement.

Background Chordomas are rare primary bone tumors that arise from the axial skeleton. Our objective was to analyze trends in radiation and surgery over time and determine location-based survival predictors for chordomas of the skull base, mobile spine, and sacrum. Methods A retrospective cohort study of the SEER (Surveillance Epidemiology and End Results) database from 1973 to 2013 was conducted. All patients had histologically confirmed chordomas. The principal outcome measure was overall survival (OS). Results The cohort included 1616 patients: skull base (664), mobile spine (444), and sacrum (508). Skull base tumors presented earliest in life (47.4 years) and sacral tumors presented latest (62.7 years). Rates of radiation remained stable for skull base and mobile spine tumors but declined for sacral tumors (P = 0.006). Rates of surgical resection remained stable for skull base and sacral tumors but declined for mobile spine tumors (P = 0.046). Skull base chordomas had the longest median survival (162 months) compared with mobile spine (94 months) and sacral tumors (87 months). Being married was independently associated with improved OS for skull base tumors (hazard ratio, 0.73; 95% confidence interval, 0.53–0.99; P = 0.044). Surgical resection was independently associated with improved OS for sacral chordomas (hazard ratio, 0.48; 95% confidence interval, 0.34–0.69; P Conclusions Surgical resection for mobile spine chordomas and radiation for sacral chordomas decreased over time. Patients with skull base tumors survived longer than did patients with mobile spine and sacral chordomas, and surgical resection was associated with improved survival in sacral chordomas only. Understanding the behavior of these tumors can help cranial and spinal surgeons improve treatment in this patient population.

Treatment paradigms for patients with spine metastases have evolved significantly over the past decade. Incorporating stereotactic radiosurgery into these paradigms has been particularly transformative, offering precise delivery of tumoricidal radiation doses with sparing of adjacent tissues. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional radiation. The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive, techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care, improving both local control and patient survivals. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists, and pain specialists. This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases, integrating these data into a decision framework, NOMS, which integrates the 4 sentinel decision points in metastatic spine tumors: Neurologic, Oncologic, Mechanical stability, and Systemic disease and medical co-morbidities.

Study Design:Retrospective Cohort Study.Objective:Octogenarians living with spinal metastases are a challenging population to treat. Our objective was to identify the rate, types, management, and predictors of complications and survival in octogenarians following surgery for spinal metastases.Methods:A retrospective review of a prospectively collected cohort of patients aged 80 years or older who underwent surgery for metastatic spinal tumor treatment between 2008 and 2019 were included. Demographic, intraoperative, complications, and postoperative follow-up data was collected. Cox proportional hazards regression and logistic regression were used to associate variables with overall survival and postoperative complications, respectively.Results:78 patients (mean 83.6 years) met inclusion criteria. Average operative time and blood loss were 157 minutes and 615 mL, respectively. The median length of stay was 7 days. The overall complication rate was 31% (N = 24), with 21% considered major and 7% considered life-threatening or fatal. Blood loss was significantly associated with postoperative complications (OR = 1.002; P = 0.02) and mortality (HR = 1.0007; P = 0.04). Significant associations of increased risk of death were also noted with surgeries with decompression, and cervical/cervicothoracic index level of disease. For deceased patients, median time to death was 4.5 months. For living patients, median follow-up was 14.5 months. The Kaplan-Meier based median overall survival for the cohort was 11.6 months (95% CI: 6.2-19.1).Conclusions:In octogenarians undergoing surgery with instrumentation for spinal metastases, the median overall survival is 11.6 months. There is an increased complication rate, but only 7% are life-threatening or fatal. Patients are at increased risk for complications and mortality particularly when performing decompression with stabilization, with increasing intraoperative blood loss, and with cervical/cervicothoracic tumors.

STUDY DESIGN Multicenter, ambispective observational study. OBJECTIVE The aim of this study was to quantify local recurrence (LR) and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intralesional procedure. SUMMARY OF BACKGROUND DATA Giant cell tumor (GCT) of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined. METHODS The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for GCT of the spine. Patients were analyzed based on surgical margins, including Enneking appropriateness. RESULTS Between 1991 and 2011, 82 patients underwent surgery for spinal GCT. According to the Enneking classification, 59 (74%) tumors were classified as S3-aggressive and 21 (26%) as S2-active. The surgical margins were wide/marginal in 27 (36%) patients and intralesional in 48 (64%) patients. Thirty-nine of 77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. Eighteen (22%) patients experienced LR. LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = 0.151). There was a significant difference between wide/marginal margins and intralesional margins for LR (P = 0.029). Seven (9%) patients died. LR is strongly associated with death (Relative Risk 8.9, P

OBJECTIVEOsteoblastoma is a rare primary benign bone tumor with a predilection for the spinal column. Although of benign origin, osteoblastomas tend to behave more aggressively clinically than other benign tumors. Because of the low incidence of osteoblastomas, evidence-based treatment guidelines and high-quality research are lacking, which has resulted in inconsistent treatment. The goal of this study was to determine whether application of the Enneking classification in the management of spinal osteoblastomas influences local recurrence and survival time.METHODSA multicenter database of patients who underwent surgical intervention for spinal osteoblastoma was developed by the AOSpine Knowledge Forum Tumor. Patient data pertaining to demographics, diagnosis, treatment, cross-sectional survival, and local recurrence were collected. Patients in 2 cohorts, based on the Enneking classification of the tumor (Enneking appropriate [EA] and Enneking inappropriate [EI]), were analyzed. If the final pathology margin matched the Enneking-recommended surgical margin, the tumor was classified as EA; if not, it was classified as EI.RESULTSA total of 102 patients diagnosed with a spinal osteoblastoma were identified between November 1991 and June 2012. Twenty-nine patients were omitted from the analysis because of short follow-up time, incomplete survival data, or invalid staging, which left 73 patients for the final analysis. Thirteen (18%) patients suffered a local recurrence, and 6 (8%) patients died during the study period. Local recurrence was strongly associated with mortality (relative risk 9.2; p = 0.008). When adjusted for Enneking appropriateness, this result was not altered significantly. No significant differences were found between the EA and EI groups in regard to local recurrence and mortality.CONCLUSIONSIn this evaluation of the largest multicenter cohort of spinal osteoblastomas, local recurrence was found to be strongly associated with mortality. Application of the Enneking classification as a treatment guide for preventing local recurrence was not validated.

Calcifying pseudoneoplasms of the neuraxis are extremely rare calcified lesions that can occur anywhere in the central nervous system. These non-neoplastic lesions have been reported to arise both in the brain and spine with similar frequency and can be found intra-axially as well as extra-axially. The associated symptoms are generally due to mass effect rather than local invasion as calcifying pseudoneoplasms of the neuraxis are usually considered to be benign non-infiltrative lesions. We report a unique case of a 67-year-old male patient who developed lower extremity weakness and gait instability with imaging and histological features of calcifying pseudoneoplasm of the neuraxis occurring in the spine with adhesive features and intradural extension. Calcifying pseudoneoplasms are benign, slow-growing masses that can present with a wide variety of symptoms depending on the size and location of the tumor. The differential diagnosis for these entities can be narrowed taking into consideration relevant imaging features as well as important clinical information.

BACKGROUND Whether primary or metastatic, tumors of the craniovertebral junction (CVJ) are rare and challenging. OBJECTIVE To examine the surgical indications, operative variables, and outcomes in patients with tumors of the CVJ undergoing occipitocervical (OC) stabilization. METHODS A single-institution, retrospective case series was performed from a prospectively maintained spine database. Patients with primary or metastatic tumors of the CVJ who underwent OC stabilization were identified. Out of 46 patients who underwent OC fusion, 39 were for tumor. Paired t -tests and Wilcoxon rank-sum tests were performed to assess for postoperative changes. RESULTS Ten patients (26%) harbored primary tumors, and the remaining 29 (74%) had metastatic disease. Of the metastatic patients, 14 had a neurological deficit, 10 had severe neck pain, and 5 were deemed mechanically unstable. Postoperative visual analog pain scores were significantly reduced at all 3 follow-up times ( P < .001, 95% confidence interval [CI; 3.2, 6.0]; P = .001, 95% CI [2.6, 7.7]; P = .020, 95% CI [0.6, 5.5]). The percentage of patients who were ambulatory and neurologically improved or intact remained stable postoperatively with no significant declines. There were 2 perioperative mortalities (5%), and 13 patients (33%) experienced a major complication. CONCLUSIONS In patients with primary or metastatic tumor of the CVJ, OC stabilization using a cervical screw-rod system affixed to a midline-keel buttress plate, with or without posterior decompression, is a reliable method for CVJ stabilization in the oncologic setting. Improvement in pain and preservation of neurological function was seen.

Study design Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with neurologic deficits secondary to metastatic epidural spinal cord compression (MESCC). Clear understanding of these factors will guide surgical decision-making by helping to elucidate which patients are more likely to benefit from surgery and how surgeons can increase the probability of neurologic and functional restoration. Summary of background data Surgical spinal cord decompression has been shown to improve neurologic function in patients with symptomatic MESCC. However, prognostication of neurologic improvement after surgery remains challenging, owing to sparse data and complexity of these patients. Methods PubMed and Embase databases were searched for relevant publications. PRISMA Statement guided publication selection and data reporting. GRADE guidelines were used for evidence quality evaluation and recommendation formulation. Results Low-quality evidence supports the use of the duration and severity of neurologic deficit as predictors of neurological recovery in patients with MESCC. Low-quality evidence supports the use of thoracic level of compression and previous irradiation as adverse predictors of neurological recovery. Nearly all of the AOSpine Knowledge Forum Tumor members who responded to the survey agreed that ambulation with assistance represented a successful surgical result and that duration of ambulation loss and the severity of weakness should be considered when trying to predict whether surgery would result in restoration of ambulation. Conclusions Review of literature and expert opinion support the importance of duration of ambulation loss and the severity of neurologic deficit (muscle strength, bladder function) in prediction of neurologic recovery among patients with symptomatic MESCC. Efforts to reduce the duration of ambulation loss and to prevent progression of neurologic deficits should be made to improve the probability of neurologic recovery. Level of evidence 2.

Study design Literature review. Objective To describe advancements in molecular techniques, biomarkers, technology, and targeted therapeutics and the potential these modalities hold to predict treatment paradigms, clinical outcomes, and/or survival in patients diagnosed with primary spinal column tumors. Summary of background data Advances in molecular technologies and techniques have influenced the prevention, diagnosis, and overall management of patients diagnosed with cancer. Assessment of genomic, proteomic alterations, epigenetic, and posttranslational modifications as well as developments in diagnostic modalities and targeted therapeutics, although the best studied in nonspinal metastatic disease, have led to increased understanding of spine oncology that is expected to improve patient outcomes. In this manuscript, the technological advancements that are expected to change the landscape of spinal oncology are discussed with a focus on how these technologies will aid in clinical decision-making for patients diagnosed with primary spinal tumors. Methods A review of the literature was performed focusing on studies that integrated next-generation sequencing, circulating tumor cells/circulating tumor DNA, advances in imaging modalities and/or radiotherapy in the diagnosis and treatment of cancer. Results We discuss genetic and epigenetic drivers, aberrations in receptor tyrosine kinase signaling, and emerging therapeutic strategies that include receptor tyrosine kinase inhibitors, immunotherapy strategies, and vaccine-based cancer prevention strategies. Conclusion The wide range of approaches currently in use and the emerging technologies yet to be fully realized will allow for better development of rationale therapeutics to improve patient outcomes. Level of evidence N/A.

BACKGROUND: Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation. OBJECTIVE: To evaluate the safety and efficacy of cement augmentation via fenestrated screws. METHODS: A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2

Background:Approximately 40% of metastatic cancer patients will develop spinal metastases. The current report provides recommendations for standardization of metrics used for spinal oncology patient population description and outcome assessment beyond local control endpoints on behalf of the SPIne response assessment in Neuro-Oncology (SPINO) group. Methods:The SPINO group survey was conducted in order to determine the preferences for utilization of clinician-based and patient-reported outcome measures for description of patients with spinal metastases. Subsequently, ClinicalTrials.gov registry was searched for spinal oncology clinical trials, and measures for patient description and outcome reporting were identified for each trial. These two searches were used to identify currently used descriptors and instruments. A literature search was performed focusing on the measures identified in the survey and clinical trial search in order to assess their validity in the metastatic spinal tumor patient population. References for this manuscript were identified through PubMed and Medline searches. Results:Published literature, expert survey, and ongoing clinical trials were used to synthesize recommendations for instruments for reporting of spinal stability, epidural tumor extension, neurological and functional status, and symptom severity. Conclusions:Accurate description of patient population and therapy effects requires a combination of clinician-based and patient-reported outcome measures. The current report provides international consensus recommendations for the systematic reporting of patient- and clinician-reported measures required to develop trials applicable to surgery for spinal metastases and postoperative spine stereotactic body radiotherapy (SBRT).

Background Despite major advances in radiation and systemic treatments, surgery remains a critical step in the multidisciplinary treatment of metastatic spinal cord tumors. Objective To describe the indications, rationale, and technique of "hybrid therapy" (separation surgery and concomitant spine stereotactic radiosurgery [SRS]) along with practical nuances. Methods Separation surgery describes a posterolateral approach for circumferential epidural decompression and stabilization. The goal is to decompress the spinal cord, stabilize the spine, and create adequate separation between the neural elements and the tumor for SRS to achieve durable tumor control. Results A transpedicular route to achieve ventrolateral access and limited resection of the tumorous vertebral body is carried out. In the setting of high-grade cord compression, caution must be taken when performing the tumor decompression. "Separation" of the ventral epidural tumor component anteriorly creates space for concomitant SRS while a simple laminectomy would not adequately achieve this goal. Dissection of the posterior longitudinal ligament allows maximal ventral decompression. Gross total tumor resection is not crucial for durable tumor control using the "hybrid therapy" model. Thus, attempts at ventral tumor resection may unnecessarily increase operative morbidity. Cement augmentation of the construct or vertebral body may improve construct stability. CT myelogram is the preferred exam for postoperative SRS planning. Radiosurgical planning constitutes a multidisciplinary effort and guidelines for contouring in the postoperative setting have recently become available. Conclusion Separation surgery is an effective, well-tolerated, and reproducible surgery. It provides safe margins for concomitant SRS. Combined, this "Hybrid Therapy" allows durable local control, maintenance of spinal stability, and palliation of symptoms, while minimizing operative morbidity.

PURPOSE/OBJECTIVES The spine is a common site of metastasis from non-small cell lung cancer (NSCLC), a disease hallmarked by heterogeneity in molecular alterations. Traditional spine radiation treatment (RT) with conventionally fractionated external beam radiation therapy (cEBRT) is associated with high local failure (LF) rates in patients surviving more than 12 months. Treatment with advanced techniques including stereotactic body radiation therapy (SBRT) significantly reduces LF. We hypothesized that specific genomic mutations in NSCLC metastases impart increased risk of LF, and that treatment with SBRT would prevent LF in metastases harboring such alterations. STUDY DESIGN/SETTING Retrospective review, single institution. PATIENT SAMPLE NSCLC patients with tumor molecular profiling data who underwent spine RT with follow-up at a single institution. OUTCOME MEASURES Local control of irradiated lesions (radiographic), overall survival. METHODS Under an IRB-approved retrospective research protocol, we examined the records of 189 pathologically-confirmed lung adenocarcinoma patients who had undergone radiation therapy for spine metastases at our institution and had tumor molecular profiling via the FDA-authorized MSK-IMPACT tumor-profiling multiplex panel platform. Mutation profiles, radiation treatment details and patient follow-up were recorded. Local control was defined radiographically using spine MRI when available and CT or PET-CT in a minority of cases. cEBRT was defined as a biologically effective dose (BED) 45Gy. Cumulative incidence of LF was calculated using a competing risk analysis with R Statistical Software and examined for significance using Gray's test, stratified by alteration in canonical NSCLC driver genes. Survival after RT was calculated by the Kaplan-Meier method using GraphPad Prism software and examined for significant differences using the Log-rank (Mantel-Cox) test. Finally, radiation sensitivity was tested by clonogenic survival assay in isogenic NSCLC cell lines with CRISPR-mediated disruption of candidate genes. RESULTS We identified 189 NSCLC patients with spine metastases who underwent RT (cEBRT = 81, SBRT = 108), had available tumor profiling by MSK-IMPACT, and had at least one follow-up imaging study. There was an overall 12-month LF rate of 13.9% for all patients. When stratified by RT type, LF at 12 months after cEBRT was 24.4% vs 5.7% after SBRT (p 5%. Mutations in NF1 were associated with increased LF after RT (HR 3.63; 95% CI 1.58-8.33; p=0.002), and mutations in KEAP1 trended toward correlation with LF (HR 1.94; 95% CI 0.92-4.10; p=0.08). When stratified by RT type, mutations in NF1 and KEAP1 were significantly associated with LF after cEBRT (NF1: HR 3.72, 95% CI 1.58-8.73, p=0.003; KEAP1: HR 2.29, 95% CI 1.00-5.26, p=0.05), but not after SBRT (NF1: HR 2.52, 95% CI 0.31-20.7, p=0.39; KEAP1: HR 1.31, 95% CI 0.26-6.56, p=0.74). CRISPR-mediated disruption of NF1 with two independent guide sequences resulted in reduced radiation sensitivity in two NSCLC cell lines (H661 and H1299), as assayed by clonogenic survival assay. CONCLUSIONS LF after RT for spine metastases from lung adenocarcinoma is common, with 12-month incidence of LF=13.9% in this cohort. Progression at 12 months is more common after cEBRT as compared to SBRT (24.4% vs 5.7%), suggesting that a large subset of patients may benefit from upfront SBRT. Alterations in NF1 and KEAP1 are associated with increased risk of local progression after cEBRT, while failure after SBRT remains low even in tumors harboring these mutations. Importantly, these findings are supported by our novel preclinical data that NF1 loss of function reduces radiation sensitivity in NSCLC cells. Furthermore, it confirms preclinical results from independent laboratories showing a role for KEAP1 in radiation sensitivity. We propose that upfront SBRT for NSCLC patients harboring mutations in NF1 and KEAP1 is appropriate for prospective study. Finally, we suggest that future radiation dose escalation trials contain pre-specified stratification on molecular alteration patterns. FDA DEVICE/DRUG STATUS OF ALL MEDICAL DEVICES/MEDICATIONS DISCUSSED MSK-IMPACT Tumor-Profiling Multiplex Panel. FDA-authorized.

BACKGROUND Tumor-associated sacral insufficiency fractures (SIF) present a significant clinical challenge. As survival increases for many malignancies, sacral fractures associated with metastases, sacral or extended pelvic radiation, and paraneoplastic osteoporosis are increasingly common and yet remain difficult to treat in the setting of the potentially significant morbidity of open sacral surgery. OBJECTIVE To describe our prospective experience with sacroplasty for tumor-associated lesions, including the largest series to date of radiation-induced SIF. METHODS Twenty-five patients with symptomatic SIF underwent 31 percutaneous fluoroscopy-guided sacroplasties with a median 5.8 mL of polymethyl methacrylate or a ceramic-resin composite under fluoroscopic guidance and with concurrent biopsy acquisition. Eighteen patients had fractures related to previous sacral or pelvic radiation; 4 had viable lytic lesions; and 2 had oncology-related osteoporosis. Postoperative pain reduction, procedural morbidity, and functional outcomes were recorded. RESULTS Twenty of 25 patients (80%) had reduction in their visual analog pain score at a median follow-up of 6.5 months; no patients worsened. The mean visual analog scale score decreased from 8.8 to 4.7 postprocedurally (P < .001), with significant reductions regardless of the underlying pathology (P < .001 to P < .05). Six of 13 patients with pretreatment ambulatory impairment required fewer ambulatory aids and 3 were newly ambulatory. Extravertebral cement migration was noted in 18 procedures; however, no instance was clinically relevant. Six repeat or contralateral procedures were performed. No morbidity was encountered. CONCLUSION Sacroplasty is a safe and effective option for the palliation of sacral fractures in the oncologic population.

Background Context Neoplastic spinal instability is movement-related pain or neurologic compromise under physiologic loads with the Spinal Instability Neoplastic Score (SINS) developed to facilitate diagnosis. There is a paucity of evidence that mechanical instability correlates with patient-reported symptoms and that surgical stabilization significantly improves these patient-reported outcomes (PROs). Purpose The objective of this study was to determine if SINS correlates with patient-reported preoperative pain and disability, and if surgical stabilization significantly improves PRO. Study Design A single-institution prospective cohort study was carried out. Patient Sample A total of 131 patients who underwent stabilization for metastatic spinal tumor treatment between July 2014 and August 2016 were included. Outcomes Measures Preoperative baseline and mean difference in perioperative PROs as assessed by the Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory (MDASI) were the outcome measures. Methods The SINS was analyzed as a continuous, ordinal, and categorical variable (Stable: 0–6, Indeterminate: 7–12, Unstable: 13–18). Statistical analysis was performed using Spearman rank coefficient (rho), the Kruskal-Wallis test, and an extension of the Cochran-Armitage trend test. The SINS and association between the mean differences in post- and preoperative PRO scores was analyzed using the Wilcoxon signed-rank test. Results There was a statistically significant positive correlation between increasing SINS and severity of preoperative pain with BPI average pain (rho=0.20; p=.03) and MDASI pain (rho=0.19; p=.03). Increasing SINS correlated with severity of preoperative disability with BPI walking (rho=0.19; p=.04), MDASI activity (rho=0.24; p=.006), and MDASI walking (rho=0.20; p=.03). Similar associations were noted when SINS was analyzed as an ordinal categorical variable. Stabilization significantly improved nearly all PRO measures for patients with indeterminate and unstable SINS. Significant correlations persisted when controlling for neurologic status and were not affected based on the technique of surgical stabilization used. Conclusions Patient-related outcome-based validation of SINS confirms this scoring system for diagnosing neoplastic spinal instability and provides surgeons with a tool to determine which patients will benefit from stabilization. Surgical stabilization of cancer patients with SINS consistent with mechanical instability provides significant reduction in pain and improves patient mobility independent of neurologic status and stabilization technique.

OBJECTIVE The object of this study was to determine the percentage of high-dose (1800–2600 cGy) single-fraction stereotactic radiosurgery (SF-SRS) treatments to the spine that result in peripheral nervous system (PNS) injury. METHODS All patients treated with SF-SRS for primary or metastatic spine tumors between January 2004 and May 2013 and referred to the Rehabilitation Medicine Service for evaluation and treatment of neuromuscular, musculoskeletal, or functional impairments or pain were retrospectively identified. RESULTS Five hundred fifty-seven SF-SRS treatments in 447 patients resulted in 14 PNS injuries in 13 patients. All injures resulted from SF-SRS delivered to the cervical or lumbosacral spine at 2400 cGy. The overall percentage of SF-SRS treatments resulting in PNS injury was 2.5%, increasing to 4.5% when the thoracic spine was excluded from analysis. The median time to symptom onset following SF-SRS was 10 months (range 4–32 months). The plexus (cervical, brachial, and/or lumbosacral) was affected clinically and/or electrophysiologically in 12 (86%) of 14 cases, the nerve root in 2 (14%) of 14, and both in 6 (43%) of 14 cases. All patients experienced pain and most (93%) developed weakness. Peripheral nervous system injuries were CTCAE Grade 1 in 14% of cases, 2 in 64%, and 3 in 21%. No dose relationship between SF-SRS dose and PNS injury was detected. CONCLUSIONS Single-fraction SRS to the spine can result in PNS injury with major implications for function and quality of life.

OBJECTIVE An analysis of factors contributing to durable radiographic control of spinal metastases was undertaken, drawing from a large single-institution database in an attempt to elucidate indications and dose requirements for successful treatment. METHODS All patients treated at a single institution with stereotactic radiosurgery (SRS) of the spine as first-line therapy were assessed for local progression of the treated site, defined as radiographic enlargement of the treated tumor and/or biopsy-proven evidence of active tumor cells. All patients were followed with CT, PET, or MR imaging every 3–6 months until death. Treatment decisions were made by a multidisciplinary team of radiation oncologists, neurosurgeons, and neuroradiologists. Target volumes were defined according to the international consensus guidelines and were reviewed in a multidisciplinary conference. Image-guided techniques and intensity modulation were used for every case. The tumor's histological type, gross tumor volume (GTV), dose that covers 95% of the GTV (GTV D95), percentage of GTV covered by 95% of the prescribed dose (GTV V95), planning target volume (PTV), dose that covers 95% of the PTV (PTV D95), and percentage of PTV covered by 95% of the prescribed dose (PTV V95) were analyzed for significance in relation to local control, based on time to local progression. RESULTS A total of 811 lesions were treated in 657 patients between 2003 and 2015 at a single institution. The mean follow-up and overall survival for the entire cohort was 26.9 months (range 2–141 months). A total of 28 lesions progressed and the mean time to failure was 26 months (range 9.7–57 months). The median prescribed dose was 2400 cGy (range 1600–2600 cGy). Both GTV D95 and PTV D95 were highly significantly associated with local failure in univariate analysis, but GTV and PTV and histological type did not reach statistical significance. The median GTV D95 for the cohort equal to or above the GTV D95 1830 cGy cut point (high dose) was 2356 cGy, and it was 1709 cGy for the cohort of patients who received less than 1830 cGy (low dose). In terms of PTV D95, the median dose for those equal to or above the cut point of 1740 cGy (high dose) was 2233 cGy, versus 1644 cGy for those lesions below the PTV D95 cut point of 1740 cGy (low dose). CONCLUSIONS High-dose single-session SRS provides durable long-term control, regardless of the histological findings or tumor size. In this analysis, the only significant factors predictive of local control were related to the actual dose of radiation given. Although the target volumes were well treated with the intended dose, those lesions irradiated to higher doses (median GTV D95 2356 cGy, minimum 1830 cGy) had a significantly higher probability of durable local control than those treated with lower doses (median PTV D95 2232 cGy, minimum of 1740 cGy) (p < 0.001). Patients in the high-dose cohort had a 2% cumulative rate of local failure. Histological findings were not associated with local failure, suggesting that radioresistant histological types benefit in particular from radiosurgery. For patients with a favorable prognosis, a higher dose of SRS is important for long-term outcomes.

BACKGROUND AND PURPOSE: Spinal instrumentation plays a key role in the treatment of spinal instability in patients with metastatic tumors. Poor bone quality, radiation, and diffuse osseous tumor involvement present significant challenges to spinal stabilization with instrumentation and occasionally result in postinstrumentation compression fractures. Vertebral cement augmentation has been effective in the treatment of painful tumor-related compression fractures. Our objective was to describe cement augmentation options in the treatment of vertebral compression fractures associated with spinal instrumentation in patients with metastatic tumors. MATERIALS AND METHODS: Patients who underwent percutaneous vertebral cement augmentation in the treatment of instrumentation-associated vertebral compression fractures between 2005 and 2011 were included in the analysis. Only fractures that occurred within the construct or at an adjacent level were included. The change in Visual Analog Scale and need for further surgery were analyzed. RESULTS: Eleven patients met the inclusion criteria, with 8 tumors located in the thoracic spine and 3 tumors in the lumbar spine. The median time between instrumented surgery and vertebral augmentation was 5 months (1–48 months) and the median follow-up after cement augmentation was 24 months (4–59 months). A total of 22 vertebrae that were either within or immediately adjacent to the surgical instrumentation underwent vertebral augmentation. All patients reported a decrease in their pain scores (mean decrease: 6 Visual Analog Scale points; P < .003). One patient required reoperation after cement augmentation. None of the patients experienced vertebral cement augmentation–related complications. CONCLUSIONS: Vertebral cement augmentation represents a safe and effective treatment option in patients with recurrent or progressive back pain and instrumentation-associated vertebral compression fractures.

Study Design. This was a retrospective study comparing dynamic contrast–enhanced magnetic resonance (DCE-MR) perfusion with digital subtraction angiography (DSA) in determining the vascularity of spinal tumors. Objective. To report on the efficacy of DCE-MR perfusion as a potential noninvasive surrogate for measuring vascularity and thus determine the need for preoperative embolization. Summary of Background Data. Although primary spinal tumors are rare, spine metastases are relatively common and symptomatic in approximately 14% of patients. Symptomatic patients require palliation with radiotherapy and/or surgery, with possible preoperative endovascular embolization of the tumor. Methods. A retrospective review revealed 10 patients with 11 diseased vertebral bodies who had received spine DCE-MR perfusion studies and subsequently underwent spinal DSA. Processed MR data were used to calculate a blood flow ratio comparing blood flow with a diseased and an adjacent normal vertebral body. Spinal tumor vascularity was graded on the basis of angiographic tumor blush from 0 (decreased enhancement compared with a normal vertebral body) to 4 (marked tumor blush with early arteriovenous shunting). Results. Eight vertebral bodies demonstrated increased vascularity on DSA with blood flow ratios of greater than 1.8, 2 vertebral bodies demonstrated normal enhancement on DSA with cerebral blood flow (CBF) ratio of 0.55 to 1.14, and 1 vertebral body level had decreased enhancement on DSA, with a CBF ratio of 0.43. There was a strong correlation between CBF ratio and DSA score, with Spearman ρ = 0.87 (P = 0.00012). Conclusion. These data show a statistically significant correlation between CBF ratio and DSA and suggest that DCE-MR perfusion can serve as a surrogate to DSA for determining tumor vascularity in patients with extramedullary spinal metastases. Conclusion. Level of Evidence: 3

Study design Systematic literature review. Objective To assess the toxicity, common radiation doses, and local control (LC) rates of radiation therapy for chordoma of the spine and sacrum and identify the difference in LC and toxicity between adjuvant, salvage, and primary therapy using radiation. Summary of background data Chordoma of the spine is typically a low-grade malignant tumor thought to be relatively radioresistant with a high rate of local recurrence and the potential for metastases. Improved results of modern radiation therapy in the treatment of chordoma support exploration of its role in the management of primary/de novo chordoma or recurrent chordoma. Methods We conducted a systematic literature review using PubMed and Embase databases to assess information available regarding the toxicity, LC rates, and overall survival (OS) rates for adjuvant, salvage, and primary radiation therapy for spinal and sacral chordoma. Results A total of 40 articles were reviewed. Evidence quality was low or very low. The highest rates of LC and OS were with early adjuvant RT for primary/de novo disease. Salvage RT for recurrent disease has very small cohorts and thus strong conclusions were not able be made. Conclusion The use of pre- and/or post-operative photon image-guided radiotherapy (IGRT), proton or carbon ion therapy should be considered for patients undergoing surgery for the treatment of primary and recurrent chordomas in the mobile spine and sacrum, since these RT modalities may improve local control. Preoperative evaluation by the surgeon and radiation oncologist should be used to formulate a cohesive treatment plan.The use of photon IGRT or carbon ion therapy as the primary treatment of chordoma, when currently in its developmental stage, shows promise and requires clear delineation of toxicity profile and long-term local control. Level of evidence 2.

BACKGROUND: Oligometastatic disease (5 metastases) is considered an intermediate cancer state of limited metastatic capacity and improved prognosis. Hence, in recent years, treatment of oligometastatic spinal disease has trended towards more definitive, ablative therapies. Little is known about the actual prognosis of patients presenting with oligometastatic spinal disease. The focus of this study was to compare oligometastatic spine patients to those with polymetastatic disease (>5 metastases). METHODS: This is an international, multicenter analysis of prospectively collected data. Data collected included demographics, survival, local control, histology, number and location of spine metastases, epidural spine cord compression (ESCC), the Spinal Instability Neoplastic Score (SINS), systemic disease burden, and treatment details. Health-related quality of life (HrQOL) measures included; numeric rating scale (NRS) for pain, EuroQol-5D (EQ-5D-3L), short form 36 version 2 (SF-36v2) and the spine oncology study group outcomes questionnaire (SOSGOQ). RESULTS: A total of 393 patients were included, of which 215 presented with oligometastatic disease and 178 with polymetastatic disease. A significant survival advantage was found for patients presenting with oligometastatic disease compared to those with polymetastatic disease at time of initial treatment of spinal metastases. This survival advantage was noticeable in both operative and non-operative patients. Local control rates were higher in the oligometastatic group for the spinal level treated. Furthermore, both groups experienced significant improvement in multiple HrQOL measures at 6 months post-treatment with no differences in these outcome measures between the two groups. CONCLUSION: At time of treatment of spinal metastatic disease, oligometastatic disease offers a significant survival advantage compared to polymetastatic disease, regardless of treatment choice. Local control can be achieved in both groups. HrQOL measures improve in both groups post-treatment, thus demonstrating a palliative treatment benefit for all treated patients. Our results support the oligometastatic theory and the current trend of ablative treatment for oligometastatic spine disease.