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Rationale: Limited health literacy (HL) leads to poor health outcomes, psychological stress, and misutilization of medical resources. Although interventions aimed at improving HL may be effective, identifying patients at risk of limited HL in the clinical workflow is challenging. With machine learning (ML) algorithms based on readily available data, healthcare professionals would be enabled to incorporate HL screening without the need for administering in-person HL screening tools., Aims and Objectives: Develop ML algorithms to identify patients at risk for limited HL in spine patients., Methods: Between December 2021 and February 2023, consecutive English-speaking patients over the age of 18 and new to an urban academic outpatient spine clinic were approached for participation in a cross-sectional survey study. HL was assessed using the Newest Vital Sign and the scores were divided into limited (0-3) and adequate (4-6) HL. Additional patient characteristics were extracted through a sociodemographic survey and electronic health records. Subsequently, feature selection was performed by random forest algorithms with recursive feature selection and five ML models (stochastic gradient boosting, random forest, Bayes point machine, elastic-net penalized logistic regression, support vector machine) were developed to predict limited HL., Results: Seven hundred and fifty-three patients were included for model development, of whom 259 (34.4%) had limited HL. Variables identified for predicting limited HL were age, Area Deprivation Index-national, Social Vulnerability Index, insurance category, Body Mass Index, race, college education, and employment status. The Elastic-Net Penalized Logistic Regression algorithm achieved the best performance with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and Brier score of 0.179., Conclusion: Elastic-Net Penalized Logistic Regression had the best performance when compared with other ML algorithms with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and a Brier score of 0.179. Over one-third of patients presenting to an outpatient spine center were found to have limited HL. While this algorithm is far from being used in clinical practice, ML algorithms offer a potential opportunity for identifying patients at risk for limited HL without administering in-person HL assessments. This could possibly enable screening and early intervention to mitigate the potential negative consequences of limited HL without taxing the existing clinical workflow., (© 2024 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Background Context: Survival prediction models for patients with spinal metastases may inform patients and clinicians in shared decision-making., Purpose: To externally validate all existing survival prediction models for patients with spinal metastases DESIGN: Prospective cohort study using retrospective data PATIENT SAMPLE: 953 patients OUTCOME MEASURES: Survival in months, area under the curve (AUC), and calibration intercept and slope METHOD: This study included patients with spinal metastases referred to a single tertiary referral center between 2016-2021. Twelve models for predicting 3, 6, and 12-month survival were externally validated Bollen, Mizumoto, Modified Bauer, New England Spinal Metastasis Score, Original Bauer, Oswestry Spinal Risk Index (OSRI), PathFx, Revised Katagiri, Revised Tokuhashi, Skeletal Oncology Research Group Machine Learning Algorithm (SORG-MLA), Tomita, and Van der Linden. Discrimination was assessed using (AUC) and calibration using the intercept and slope. Calibration was considered appropriate if calibration measures were close to their ideal values with narrow confidence intervals., Results: In total, 953 patients were included. Survival was 76.4% at 3 months (728/953), 62.2% at 6 months (593/953), and 50.3% at 12 months (479/953). Revised Katagiri yielded AUCs of 0.79 (95%CI 0.76;0.82) to 0.81 (95%CI 0.79;0.84), Bollen yielded AUCs of 0.76 (95%CI 0.73;0.80) to 0.77 (95%CI 0.75;0.80), and OSRI yielded AUCs of 0.75 (95%CI 0.72;0.78) to 0.77 (95%CI 0.74;0.79). The other nine prediction models yielded AUCs ranging from 0.59 (95%CI 0.55;0.63) to 0.76 (95%CI 0.74;0.79). None of the twelve models yielded appropriate calibration., Conclusions: Twelve survival prediction models for patients with spinal metastases yielded poor to fair discrimination and poor calibration. Survival prediction models may inform decision-making in patients with spinal metastases, provided that recalibration using recent patient data is performed., Funding: This study was funded by the AOSpine under the Discovery & Innovation award (AOS-DIA-22-012-TUM). A total amount of CHF 40,000 ($45,000) was received., Competing Interests: Declaration of competing interest None, (Copyright © 2025. Published by Elsevier Inc.)

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.

This narrative review provides a comprehensive overview of the current status, recent advancements, and future directions in the management of metastatic spine disease using both radiotherapy and surgery. Emphasis has been put on the integrated use of radiotherapy and surgery, incorporating recent developments such as separation surgery, active dose sparing of the surgical field, and the implementation of carbon fiber-reinforced polymer implants. Future studies should explore the effects of minimizing the time between radiotherapy and surgery and investigate the potential of vertebral re-ossification after radiotherapy to obviate the need for stabilization surgery. Concerted efforts should be directed toward fostering multidisciplinary collaboration among radiation oncologists, spine surgeons, and medical oncologists., (© The Author(s) 2025. Published by Oxford University Press.)

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.

Purpose: The SORG-MLA was developed to predict 90-day and 1-year postoperative survival in patients with spinal metastatic disease who underwent surgery between 2000 and 2016. Due to the constant changes in treatment methods, it is essential to perform temporal validation with a recent patient population. Therefore, the purpose of this study was to validate the Skeletal Oncology Research Group machine learning algorithms (SORG-MLA) using a contemporary patient cohort., Methods: This retrospective cohort study investigated patients who received surgical treatment for spinal metastases between January 2017 and July 2021 in two tertiary care centers in the US. Eighteen input variables needed for the SORG-MLA were collected including primary tumor, Eastern Cooperative Oncology Group (ECOG) Performance Status, and nine preoperative laboratory values. Outcomes were defined as mortality at 90-day and 1-year postoperative. Performance was assessed using calibration, discrimination, overall performance, and decision curve analysis., Results: In total, 464 patients were included. The validation cohort varied from the development cohort in multiple variables. Despite these differences, the SORG-MLA continued to perform well on calibration, discrimination (area under the receiver operating characteristic curve [AUC] 0.81 (95% confidence interval [CI], 0.77-0.86) for 90-day, AUC 0.75 (95% CI, 0.71-0.80) for 1-year), Brier score, and decision curve analyses., Conclusions: In spite of recent progress in treating spinal metastases, SORG-MLA for survival in patients with spinal metastatic disease continued to perform well on temporal validation. However, updating the models using a contemporary patient cohort and stratifying by primary tumor could further improve the performance., Competing Interests: Approval: investigation performed at Massachusetts General Hospital, Boston USA. Local Institutional Review Board (IRB) approval was obtained for this study (registration number 2013P002411). Financial disclosures: each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: Retrospectively matched case-control study., Objective: To compare intraoperative and postoperative outcomes between separation surgery and corpectomy with anterior reconstruction for patients with metastatic epidural spinal cord compression (MESCC)., Summary of Background Data: The primary goal of surgery for MESCC is to preserve and improve neurological function. Separation surgery may offer a less invasive alternative that still achieves neurological decompression and restores biomechanical stability, enabling surgeons to forego more invasive surgeries, such as corpectomy with anterior reconstruction. However, there is limited literature comparing these two surgical methods., Methods: Fifty-six patients aged 18 years or older who underwent either separation surgery followed by stereotactic body radiation therapy (n=28) or corpectomy with anterior reconstruction (n=28) for MESCC from 2017 to 2022 were included. Outcomes included estimated blood loss, operating time, intraoperative blood transfusion and complications. The Mann-Whitney U test was used for continuous data, and Fisher's exact test for categorical data., Results: Patients undergoing separation surgery compared with anterior reconstruction experienced less blood loss (median 500 ml [IQR 300-1,000] vs. 925 ml [IQR 500-1,425]; P=0.036) and shorter operating times (median 214 minutes [IQR 164-281] vs. 286 minutes [IQR 220-328]; P=0.028). Intraoperative blood transfusion occurred in seven patients (25%) in the separation surgery group versus 14 patients (50%) in the anterior reconstruction group (P=0.10). There were no significant differences between both groups with regard to duration of hospitalization, complications, postoperative transfusions, reoperations, or survival (P<0.05)., Conclusion: Separation surgery was found to have less blood loss and shorter operating times compared with corpectomy with anterior reconstruction. These findings suggest that separation surgery may be a viable therapeutic alternative for MESCC patients currently undergoing more invasive surgical approaches. Future studies should prospectively compare separation surgery and corpectomy with anterior reconstruction to provide additional evidence on their relative effectiveness in managing local tumor control., Level of Evidence: Treatment benefits, Level IV., Competing Interests: Conflict of interest and source of funding: Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. None of the authors had any conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Detecting spinal metastases is highly relevant in patients with oncological disorders as it can affect the staging and treatment of their disease. We aimed to evaluate the diagnostic performance of computed tomography (CT), magnetic resonance imaging (MRI), FDG positron emission tomography (PET)/CT, bone scintigraphy (BS), and single-photon emission computed tomography (SPECT) for spinal metastases detection., Methods: Medline, EMBASE, and Web of Science were systematically searched until March 2024 for diagnostic accuracy studies on spinal metastases detection (PROSPERO-registration: CRD42024540139). Data extraction and quality assessment using the QUADAS-2 tool were performed by two independent reviewers. Using bivariate random effects modeling, pooled sensitivities, specificities, and diagnostic odds ratios (DOR) were calculated, and hierarchical summary operating curves were constructed., Results: Twenty-five studies (49 datasets), encompassing 3102 patients were included. Per-patient pooled sensitivities of CT, MRI, PET/CT, BS and SPECT were 70%, 93%, 82%, 75%, and 84%, respectively. Pooled specificities were 74%, 85%, 75%, 92%, and 81%, respectively. Per-lesion pooled sensitivities of CT, MRI, PET/CT, BS and SPECT were 76%, 91%, 92%, 77%, and 92%, respectively. Pooled specificities were 91%, 94%, 85%, 52%, and 86%, respectively. MRI had the highest DOR in per patient and lesion analyses., Conclusion: MRI had highest diagnostic accuracy for spinal metastases detection on patient and lesion level, suggesting a broader use in addition to the routine staging CT, at least in patients at high risk and where the detection of a spinal metastasis could alter therapy decisions. Herein, results should be considered with the limitations of each modality., (© 2024. The Author(s).)

Study Design: Retrospective propensity-score matched, case control study at 2 academic tertiary care centers., Objective: To assess the effect of PE on (1) intraoperative blood loss, defined as conventional estimates of blood loss (EBL) and hemoglobin mass loss, and (2) secondary outcomes in patients with spinal metastases from hypervascular histologies., Background Context: Preoperative embolization (PE) intends to reduce blood loss during surgery for spinal metastases of hypervascular tumors such as renal cell carcinoma. However, studies investigating the effect of PE in hypervascular tumors often consist of small cohorts, do not correct for confounding factors, and have conflicting results., Methods: After propensity score matching (PSM), 46 PE patients were matched to 46 non-PE patients without baseline differences. The constraints of PSM did not allow analysis of patients with tumor volumes>9 cm 3 . Multiple linear regression models were fitted for EBL and hemoglobin mass loss. Poisson regression models were fitted for both intraoperative and postoperative transfusions., Results: There was no difference in EBL (948 mL [IQR 500-1750] vs. 1100 mL [IQR 388-1925], P =0.68) and hemoglobin mass loss (201g [IQR 119-307] vs. 232g [IQR 173-373], P =0.18) between PE and non-PE patients. Other than higher 1-year survival rates (65% vs. 43%, P =0.05) in PE-patients, there were no differences in secondary outcomes. In multiple regression analyses, PE was not associated with decreased intraoperative blood loss, hemoglobin mass loss or perioperative blood transfusions., Conclusions: Our study demonstrated that, for tumors <9 cm 3 , PE did not reduce EBL, hemoglobin mass loss or perioperative blood transfusions in patients undergoing spine surgery for metastases from hypervascular histologies. These findings suggest that urgent spine surgeries indicated for hypervascular histologies should not be delayed based on the availability of PE and accurate detection of pre-operative hypervascularity, beyond histology, will likely be an important determination of future PE utilization for spinal metastases., Level of Evidence: Treatment Benefits, Level III., Competing Interests: Conflicts of Interest and Source of Funding : each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. None of the authors had any conflicts of interests., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose: Currently no minimally invasive surgical treatment exists to provide immediate stability for unstable cervical/cervicothoracic metastases. Long-construct spondylodesis carries a high complication risk and has severe impact on residual range of motion. This study explores temporary halo fixation and radiotherapy as an alternative to long-construct cervical spondylodesis., Materials and Methods: This retrospective cohort study included twenty patients with multiple unstable cervical metastases treated between 2013-2023. All patients underwent halo fixation for an intended duration of three months to allow for safe reossification of lytic lesions following radiotherapy, with a dose fractionation scheme best suited to the histological origin of the tumor., Results: Immobilization with halo fixation lasted a median 83 days (range, 41-132 days). Radiotherapy started on average 7 days after halo fixation (range, -35-118 days). The median pain score at baseline was 8, and was 0 at halo removal and at last follow-up. All patients had no or minor neurological deficits at baseline and did not develop new neurological deficits. At halo removal, 17/18 patients showed radiographic evidence of reossification. The majority of patients experienced minor limitations or had full range of motion of the neck at last follow-up., Conclusion: Patients with multiple unstable cervical metastases treated with halo fixation and radiotherapy showed complete pain response or substantial pain reduction, reossification of the vertebrae and a, mostly, preserved range of motion. In selected neurologically intact patients, this treatment might be a patient-friendly alternative to fixation. Prospective evaluation of this treatment combination is needed., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

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.

Purpose: To assess whether the intention to intraoperatively reposition pedicle screws differs when spine surgeons evaluate the same screws with 2D imaging or 3D imaging., Methods: In this online survey study, 21 spine surgeons evaluated eight pedicle screws from patients who had undergone posterior spinal fixation. In a simulated intraoperative setting, surgeons had to decide if they would reposition a marked pedicle screw based on its position in the provided radiologic imaging. The eight assessed pedicle screws varied in radiologic position, including two screws positioned within the pedicle, two breaching the pedicle cortex < 2 mm, two breaching the pedicle cortex 2-4 mm, and two positioned completely outside the pedicle. Surgeons assessed each pedicle screw twice without knowing and in random order: once with a scrollable three-dimensional (3D) image and once with two oblique fluoroscopic two-dimensional (2D) images., Results: Almost all surgeons (19/21) intended to reposition more pedicle screws based on 3D imaging than on 2D imaging, with a mean number of pedicle screws to be repositioned of, respectively, 4.1 (± 1.3) and 2.0 (± 1.3; p < 0.001). Surgeons intended to reposition two screws placed completely outside the pedicle, one breaching 2-4mm, and one breaching < 2 mm more often based on 3D imaging., Conclusion: When provided with 3D imaging, spine surgeons not only intend to intraoperatively reposition pedicle screws at risk of causing postoperative complications more often but also screws with acceptable positions. This study highlights the potential of intraoperative 3D imaging as well as the need for consensus on how to act on intraoperative 3D information., (© 2024. The Author(s).)