Perioperative complication and surgical outcome in patients with spine metastases: Retrospective 200-case series in a single institute

doi:10.1016/j.clineuro.2014.04.025

Clinical Neurology and Neurosurgery

Volume 122, July 2014, Pages 80-86

https://doi.org/10.1016/j.clineuro.2014.04.025 Get rights and content

Highlights

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This study demonstrated 200 patients of spinal metastases from a single institute between 2005 and 2010.
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Postoperative neurologic status affected the postoperative survival depending on the surgery type (en bloc excision, debulking curettage, and palliative surgery).
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Debulking operation demonstrated highest incidence of perioperative complications, despite the fact that there were no differences in the improvement of neurologic deficits after surgery.

Abstract

Objective

Metastatic spinal disease requires a multidisciplinary approach with advanced surgical techniques which improve longevity and the quality of life. The purpose of this study is to compare the surgical outcomes and perioperative complications and mortality among en bloc, debulking, and palliative surgeries in patients with spinal metastasis.

Methods

From 2005 to 2010, 200 patients who underwent surgical treatment for spinal metastases were enrolled retrospectively. Clinical analysis included primary cancer type, survival following the diagnosis of cancer, postoperative survival, Tokuhashi score, postoperative functional status, postoperative complications and mortality depending on the surgery type. Enrolled patients were divided into 3 groups: en bloc excision, debulking curettage, and palliative surgery. Surgical outcomes including perioperative complication and mortality were compared based on the surgery type.

Results

The mean age was 59.9 years (range 21–87). The major types of primary cancer were lung (42 cases), liver (27 cases), and colorectal cancer (27 cases). 62 surgeries (31.0%) were en bloc excisions, 82 (41.0%) were debulking, and 56 (28.0%) were palliative operations. The mean Tokuhashi score was 9.2 ± 3.3 in the en bloc group, 7.2 ± 3.0 in the debulking group and 8.2 ± 2.6 in the palliative group (p = 0.001, ANOVA). Mean postoperative survivals were 17.9 ± 22.1 months in the en bloc group, 7.0 ± 11.7 months in the debulking group and 8.5 ± 10.8 months in the palliative group (p = 0.022, ANOVA). There were 8 (12.9%) postoperative complications in the en bloc group, 17 (20.7%) in the debulking group, and 8 (14.3%) in the palliative group (p = 0.016, chi-square). Three patients (4.8%) in the en bloc group had multiple complications, as did 5 (6.1%) in the debulking group and 2 (3.6%) in the palliative group (p = 0.925, chi-square). Among 21 total perioperative deaths, 6 (28.6%) were in the en bloc group, 10 (47.6%) in the debulking group, and 5 (23.8%) in the palliative group (p = 0.618, chi-square).

Conclusion

Postoperative complications were most common in the debulking group compared to the en bloc and palliative groups, despite the fact that there were no differences in the improvement of neurologic deficits after surgery. Therefore, selecting the proper surgery based on the patients' symptoms and neurologic status is of great significance in the planning stage of the surgery.

Introduction

Geriatric populations are at increased risk for cancer, and as their population increases worldwide, so does the incidence of spinal metastasis [1]. Thus, spine specialists are encountering patients with spinal metastasis more often. Advanced multimodular treatments have improved the life expectancies of these patients [1], [2]. Many authors have reported the results of various surgical techniques on progressed spinal metastases [3], [4], [5]. The high complication rates of surgical techniques must be weighed against the benefits, otherwise patients can undergo unnecessarily massive procedures, shorten the patients’ lifespan, and lower their quality of life [6]. Therefore, surgical outcomes including postoperative survival, perioperative complications and mortality should be analyzed and compared to the various surgical techniques, from the less aggressive palliative method to an en-bloc excision, which is the most aggressive. With this vital information, spinal surgeons can choose the optimal surgical techniques in treating patients with spinal metastasis by weighing the risks and benefits. Accordingly the purpose of this particular study is to compare the surgical outcomes; i.e., postoperative survival, perioperative complications and mortality among the available surgical options, such as en bloc, debulking, and palliative surgeries in patients with spinal metastasis.

Section snippets

Materials and methods

From 2005 to 2010, 200 patients who underwent surgical treatment for spinal metastases were listed based on the World Health Organization (WHO) International Statistical Classification of Diseases and Related Health Problems, 10th Revision, 2007, known as ICD-10. Secondary malignant neoplasm of bone and bone marrow code (C79.5) were searched by an electronic medical record search program. The medical records for all enrolled patients were reviewed thoroughly to confirm spinal metastasis and

Results

This study enrolled 200 patients comprising 118 males and 82 females. The major primary cancers were lung cancer in 42 cases (21.0%), liver cancer in 27 (13.5%), colorectal cancer in 27 (13.5%), renal cancer in 22 (11.0%), breast cancer in 15 (7.5%), thyroid cancer in 11 (5.5%), stomach cancer in 7 (3.5%), prostate cancer in 6 (3.0%), and multiple myeloma in 6 (3.0%) (Table 1). The mean age was 59.7 ± 12.4 (range 21–87). There were no differences in demographics and distribution of primary cancer

Discussion

As adjuvant therapies have improved, patients with metastases are living longer after diagnosis [10], [11]. In previous decades, patients with spinal metastases were considered to be in the terminal stage of their disease and thus required only palliative surgical treatments [12]. New radiologic imaging and surgical techniques, however, have made it possible to detect the earliest spinal metastatic lesions and properly treat spinal metastases. Moreover, recent technique such as tomotherapy

Conclusion

Postoperative complications were most common in the debulking group compared to those in en bloc and palliative groups, despite the fact that there were no differences in the improvement of neurologic deficits after surgery. Therefore, selecting the proper surgery based on the patients’ symptoms and neurologic status, as well as paying closer attention to reducing perioperative complications during surgery, can result in better control of spinal metastasis and possibly a better quality of life

Source of funding

None.

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A Novel Prognostication System for Spinal Metastasis Patients Based on Network Science and Correlation Analysis
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Citation Excerpt :
Surgery can improve the quality of life of patients and preserve or restore neurological function [5,6], but the assessment of the appropriate, personalised surgical procedure is often difficult. Considering possible complications [7,8], the surgery team can select cases where the operation is risky and the gain in quality of life is low compared with the risks of the intervention. The therapeutic decision-making process is guided by prognostic factors, but as the number of coefficients increases, it becomes very difficult to choose the ones that have the largest impact on the survival of an individual patient.
During the progress of oncological diseases, there is an increased probability that spinal metastases may develop, requiring personalised treatment options. Risk calculator systems aim to provide assistance in the therapeutic decision-making process by estimating survival chances. The predictive ability of such calculators can be improved, thereby optimising the choice of personalised therapy. The aim of this research was to create a new risk assessment system and show a method with which other centres can develop their own local score.
We created a database by retrospectively processing 454 patients. The prognostic factors were selected via a network science-based correlation analysis that maximises Uno's C-index, keeping only a small number of predictors. To validate the new system, we calculated the D-statistic, the Integrated Discrimination Index, made a five-fold cross-validation and also calculated the integrated time-dependent Brier score.
As a result of multivariate Cox analysis, we found five independent prognostic factors suitable for the design of the risk calculator. This new system has a better predictive ability compared with six other well-known systems with an average C-index of 0.706 at 10 years (95% confidence interval 0.679–0.733).
An accurate estimation of the life expectancy of cancer patients is essential for the implementation of personalised medicine. The training performance of our system is encouraging, indicating the benefit of a network science-based visualisation step. We believe that in order to further improve the prediction ability, it is necessary to systematise previously ‘unknown’ factors (e.g. radiological morphology).
Wound-related complications in the surgical treatment of vertebral metastatic disease – A case series analysis
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Spinal metastases (SM) account for 5–30% of patients with cancer, causing pain, deformity and/or neurological deficit. Postoperative complications are a concerning subject and wound-related complications (WRC) may delay adjuvant treatment. The objective of this study was to analyze the incidence of WRC in patients with SM that underwent surgical treatment as well as possible risk factors related to the occurrence of complications.
Patients with SM operated between 2011 and 2021 were analyzed. Demographics characteristics, primary tumor, general and neurological status, Tokuhashi score, type of surgical treatment, surgical length, preoperative serum albumin and hemoglobin, pre and postoperative adjuvant treatment were analyzed. The incidence and risk factors of WRC – surgical site infection, hematoma, and/or dehiscence – at 90 days was evaluated. Patients were classified in two groups according to the absence/presence of WRC.
198 patients (121 males and 77 females) with an average age of 65 years (range 54–73 years) were analyzed. WRC were observed in 44 patients (22%). On multivariable analysis, significant predictors for developing WRC were low Tokuhashi score (OR = 7.89, 95% CI = 1.37–45.35, p = 0.021), prostate cancer as primary tumor (6.73, 1.14–39.65, p = 0.035), and preoperative serum albumin level ≤3.5 g/dL (2.31, 1.02–5.22, p = 0.044). There was no difference between groups on 90 days survival rate (p = 0.714).
In our series, the incidence of WRC was 22%, main risk factors for complications were low Tokuhashi score, lower preoperative serum albumin, and prostate cancer. Finally, short-term survival rate was not affected by the occurrence of WRC.
Las metástasis espinales (MV) pueden ocurrir en el 5-30% de los pacientes con cáncer, provocando dolor, deformidad y/o déficit neurológico. Las complicaciones postoperatorias son un motivo de preocupación y las complicaciones relacionadas con la herida (CRH) pueden retrasar el inicio del tratamiento adyuvante. El objetivo de este estudio fue analizar la incidencia de CRH en pacientes con MV sometidos a tratamiento quirúrgico y evaluar los posibles factores de riesgo relacionados con estas complicaciones.
Se analizaron pacientes operados por MV entre 2011 y 2021. Se analizaron características demográficas, tumor primario, estado general y neurológico, score de Tokuhashi, tipo de tratamiento quirúrgico, duración de la cirugía, albúmina sérica y hemoglobina preoperatorias, tratamiento adyuvante pre- y postoperatorio. Se evaluó la incidencia y los factores de riesgo de la CRH (infección del sitio quirúrgico, hematoma y/o dehiscencia) a los 90 días. Los pacientes se clasificaron en dos grupos según la ausencia/presencia de CRH.
Se analizaron 198 pacientes (121 hombres y 77 mujeres) con una edad promedio de 65 años (rango 54-73 años). Se observaron CRH en 44 pacientes (22%). En el análisis multivariado, los predictores significativos para el desarrollo de CRH fueron un score de Tokuhashi bajo (OR = 7,89; IC del 95% = 1,37-45,35; p = 0,021), cáncer de próstata como tumor primario (OR = 6,73; IC del 95% = 1,14-39,65; p = 0,035) y albúmina sérica preoperatoria ≤ 3,5 g/dL (OR = 2.31; IC del 95% = 1,02-5,22; p = 0,044). No hubo diferencias entre los grupos en la supervivencia a los 90 días (p = 0,714).
En nuestra serie, la incidencia de CRH fue del 22%, los principales factores de riesgo para su aparición fueron el score de Tokuhashi bajo, la albúmina sérica preoperatoria más baja y el cáncer de próstata. Finalmente, la tasa de supervivencia a corto plazo no se vio afectada por la ocurrencia de CRH.
Predictive value of hypoalbuminemia and severe hypoalbuminemia in oncologic spine surgery
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Retrospective review of a prospectively collected national database.
To evaluate the predictive value of hypoalbuminemia on outcomes in surgical spine oncology patients.
It is well documented that patients with hypoalbuminemia (albumin <3.5) have significantly higher rates of surgical morbidity and mortality than patients with normal albumin (>3.5 g/dl). We evaluated outcomes for metastatic oncologic spine surgery patients based on pre-operative albumin levels.
Patients who underwent surgery for metastatic spine disease were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. Three groups were established: patients with normal albumin (>3.5 g/dl), mild hypoalbuminemia (2.6 g/dl – 3.4 g/dl), and severe hypoalbuminemia (<=2.5 g/dl). A multivariate analysis was used to assess the association between albumin levels and mortality within 30 days of surgical intervention.
A total of 700 patients who underwent surgery for metastatic spinal disease and had pre-operative albumin levels available were identified; 64.0% had normal albumin (>3.5 g/dl), 29.6% had mild hypoalbuminemia, and 6.4% had severe hypoalbuminemia. The overall 30-day mortality was 7.6% for patients with normal albumin, 15.9% for patients with mild hypoalbuminemia, and 44.4% for patients with severe hypoalbuminemia. On multivariate analysis, patients with mild hypoalbuminemia (OR 1.7 95% CI: 1.0–3.0 p = 0.05) and severe hypoalbuminemia (OR 6.2 95% CI: 2.8–13.5 p < 0.001) were more likely to expire within 30 days compared to patients with preoperative albumin above 3.5 g/dl.
In this study, albumin level was found to be an independent predictor of 30-day mortality in patients who underwent operative intervention for metastatic spinal disease. Patients with severe hypoalbuminemia had a 7-fold increased risk when compared with those who had normal albumin. While these findings need to be validated by future studies, we believe they will prove useful for preoperative risk stratification and surgical decision-making
Risk predictors of perioperative complications for the palliative surgical treatment of spinal metastasis
2021, Journal of Orthopaedic Science
Citation Excerpt :
In the present study, perioperative complications developed in 15% of 195 consecutive patients who received palliative surgery with posterior procedures for spinal metastasis. Although a wide range of perioperative complication rates of palliative surgery for spinal metastasis has been reported from 5.3% to 76.2% [7], the complication rate is limited from 14% to 35% in all but one large-scale study (over 100 participants) [4–6,8–13,20,21]. Lau et al. described a 21.7% perioperative complication rate in 106 patients [6].
The complication rate for palliative surgery in spinal metastasis is relatively high, and major complications can impair the patient's activities of daily living. However, surgical indications are determined based primarily on the prognosis of the cancer, with the risk of complications not truly considered. We aimed to identify the risk predictors for perioperative complications in palliative surgery for spinal metastasis.
A multicentered, retrospective review of 195 consecutive patients with spinal metastasis who underwent palliative surgeries with posterior procedures from 2001 to 2016 was performed. We evaluated the type and incidence of perioperative complications within 14 days after surgery. Patients were categorized into either the complication group (C) or no-complication group (NC). Univariate and multivariate analyses were used to identify potential predictors for perioperative complications.
Thirty patients (15%) experienced one or more complications within 14 days of surgery. The most frequent complications were surgical site infection (4%) and motor weakness (3%). A history of diabetes mellitus (C; 37%, NC; 9%: p < 0.01) and surgical time over 300 min (C; 27%, NC; 12%: p < 0.05) were significantly associated with complications according to univariate analysis. Increased blood loss and non-ambulatory status were determined to be potential risk factors. Of these factors, multivariate logistic regression revealed that a history of diabetes mellitus (OR: 6.6, p < 0.001) and blood loss over 1 L (OR: 2.7, p < 0.05) were the independent risk factors for perioperative complications. There was no difference in glycated hemoglobin A1c between the diabetes patients with and without perioperative complications.
Diabetes mellitus should be used for the risk stratification of surgical candidates regardless of the treatment status, and strict prevention of bleeding is needed in palliative surgeries with posterior procedures to mitigate the risk of perioperative complications.
Spinal metastases from lung cancer: Survival depends only on genotype, neurological and personal status, scarcely of surgical resection: Survival in spine metastases from lung cancer
2020, Surgical Oncology
For patients with non–small cell lung cancer (NSCLC), the spinal column is the most common site for bone metastasis. Studies that assess survival prognostic factors associated with specific lung spinal metastases (SpM) are weak and required the incorporation of genotype mutations.
A prospective French national multicenter database of patients treated for SpM between January 2014 and 2017.818 lung SpM were diagnosed over the course or at the time of diagnosis of 210 consecutive patients with NSCLC.
Median overall survival (OS) time for all patients from the lung SpM event was 5.9 months (SD 0.609). For 122 patients (61%), lung tumor and SpM were diagnosed synchronously. In univariate analysis, good World Health Organisation (WHO) status (p < 0.0001), ambulatory status (Frankel score) (p < 0.0001), the absence of spine epiduritis (p < 0.0001), immunotherapy after SpM diagnosis (p < 0.0001), ALK gene rearrangement (p < 0.0001) and EGFR mutation (p < 0.0001) were associated with longer survival, whereas spine surgery showed no association (0.141). Cox multivariate proportional hazard model identified that EGFR + status (HR: 0.339, 95% CI 0.166–0.693; p = 0.003), good WHO status (p < 0.0001) and good neurological status (Frankel E; p < 0.001 and D; p = 0.018) were associated with higher median OS. Whereas the other factors, including ALK + status, epiduritis and immunotherapy were not independent prognostic factors of survival.
Survival in SpM must be prognosticated from general health performance status: clinical (WHO) and neurological (Frankel) as well as the EGFR mutation status. Immunotherapy, surgery and epiduritis have not demonstrated prognostic value. Therefore, surgical prognostic scoring algorithms should incorporate genotype subtypes in NSCLC cancers to adapt surgical treatment.
Survival in breast cancer patients with spine metastases: Prognostic assessment involving molecular markers
2020, European Journal of Surgical Oncology
To clarify and update the prognostic assessment for heterogeneous population of patients with breast cancer and spine metastases (SpM), using molecular markers.
The patient data used in this study was obtained from a French national multi-center database of patients treated for breast cancer with SpM between 2014 and 2017. 556 SpM cases were diagnosed.
Median overall survival (OS) time for all patients following the SpM event was 43.9 months. First, we confirmed 3 previously known significant prognostic factors for survival of patients with SpM: young age [HR: 2.019, 95% CI 1.343–3.037; p = 0.001], good WHO status [ Status 0 HR: 2.823, 95% CI 1.231–3.345; p < 0.0001] or [ Status 1 HR: 1.956, 95% CI 0.768–2.874; p = 0.001] and no-ambulatory neurological status: Frankel A-C [HR: 0.438, 95% CI 0.248–0.772; p = 0.004]. Secondly, we determined the effect of gene mutations on survival in patients with SpM, and we identified that HER2+ cancer subtype [HR: 1.567, 95% CI 0.946–2.557; p = 0.008] was an independent predictor of longer survival, whereas basal cancer subtype [HR: 0.496, 95% CI 0.353–0.699; p < 0.0001] was associated with a poorer prognosis. Other factors including the number of SpM, surgery, extraspinal metastases, synchrone metastases, metastasis-free survival, and SpM recurrence were not identified as prognostically relevant to survival.
Survival and our ability to estimate it in breast cancer patients with SpM has improved significantly. Therefore, SpM prognostic scoring algorithms should be updated and incorporate genotypic data on subtypes to make treatment more adaptive.

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^☆: All the experimental protocols involving human subjects were approved by the Institutional Review Board of each participating institution.

¹: Present address: Department of Orthopaedic Surgery, International St. Mary’s Hospital, Shimgok-dong, Seo-ku, In-Cheon, 404-834, Republic of Korea.

View full text

Perioperative complication and surgical outcome in patients with spine metastases: Retrospective 200-case series in a single institute☆

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Source of funding

Surg Neurol

Semin Oncol Nurs

Surg Oncol

J Pain Symptom Manage

Lancet

Eur J Cancer

Lancet

Surgical treatment of bone metastasis: indications and outcomes

Int J Clin Oncol

Cancer statistics

CA Cancer J Clin

Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis

Spine (Phila Pa 1976)

Surgical strategy for spinal metastases

Spine (Phila Pa 1976)

Transthoracic vertebrectomy for metastatic spinal tumors

J Neurosurg

Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007

J Neurosurg Spine

A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis

Spine (Phila Pa 1976)

Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2009

Cancer Res Treat

Metastatic spinal tumors

Neurosurg Focus

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life

Spine (Phila Pa 1976)