Search Results (18)

Background: Large language models (LLMs) have emerged as powerful tools in healthcare. In diagnostic radiology, LLMs can assist in the computation of the Spine Instability Neoplastic Score (SINS), which is a critical tool for assessing spinal metastases. However, the accuracy of LLMs in calculating the SINS based on radiological reports remains underexplored. Objective: This study evaluates the accuracy of two institutional privacy-preserving LLMs—Claude 3.5 and Llama 3.1—in computing the SINS from radiology reports and electronic medical records, comparing their performance against clinician readers. Methods: A retrospective analysis was conducted on 124 radiology reports from patients with spinal metastases. Three expert readers established a reference standard for the SINS calculation. Two orthopaedic surgery residents and two LLMs (Claude 3.5 and Llama 3.1) independently calculated the SINS. The intraclass correlation coefficient (ICC) was used to measure the inter-rater agreement for the total SINS, while Gwet’s Kappa was used to measure the inter-rater agreement for the individual SINS components. Results: Both LLMs and clinicians demonstrated almost perfect agreement with the reference standard for the total SINS. Between the two LLMs, Claude 3.5 (ICC = 0.984) outperformed Llama 3.1 (ICC = 0.829). Claude 3.5 was also comparable to the clinician readers with ICCs of 0.926 and 0.986, exhibiting a near-perfect agreement across all individual SINS components [0.919–0.990]. Conclusions: Claude 3.5 demonstrated high accuracy in calculating the SINS and may serve as a valuable adjunct in clinical workflows, potentially reducing clinician workload while maintaining diagnostic reliability. However, variations in LLM performance highlight the need for further validation and optimisation before clinical integration. Full article

Objectives: The current study aimed to evaluate the effect of denosumab on patients with impending instability due to spinal metastasis, including whether it can improve spinal instability neoplastic score (SINS) and reduce the need for surgical treatment. Methods: This study retrospectively reviewed patients initially treated non-operatively for metastatic spinal lesions with intermediate SINS (7–12 points) between January 2017 and December 2023 in a single tertiary cancer hospital. Patients were divided into two groups based on the use of denosumab for the intermediate SINS lesion: D-group and N-group. Propensity score matching (PSM) was conducted with a caliper width of 0.025 for the covariates (age, sex, and primary cancer). The study outcomes were (1) the rate of conversion to surgery, (2) the change in SINS, and (3) the change in HU (Hounsfield unit) during the follow-up period. Results: A total of 286 patients (male 151, female 135) with a mean age of 68.0 ± 12.6 years and a mean follow-up period of 37.1 ± 26.5 months were included. Forty-one (14.3%) patients received denosumab (D-group), whereas 245 (85.7%) did not receive denosumab (N-group). Before PSM, 9.8% (4/41) in the D-group and 18.8% (46/245) in the N-group underwent surgical treatment. The rate of conversion to surgery was similar after PSM: the D-group, 8.3% (3/36) vs. the N-group, 16.6% (6/36). Survival analysis using Kaplan–Meier curves also showed that the D-group had a significantly lower probability of conversion to surgery before and after PSM (p = 0.015 and p = 0.023, respectively). In addition, the D-group showed significant improvements in the SINS (total score, pain, and bone lesion scores) and HU after denosumab treatment. Conclusions: In this study, denosumab lowered the rate of conversion to surgery in patients with impending instability (intermediate SINS) due to spinal metastasis. Patients who received denosumab treatment showed significant improvements in the SINS and HU for their metastatic spinal lesions. Full article

Background: Patients with vertebral metastases often experience spinal instability, chronic pain, and psychological distress, all of which can significantly reduce quality of life. Spinal instability, measured by the Spinal Instability Neoplastic Score (SINS), may exacerbate functional impairment and emotional distress, underscoring the potential benefit of personalized recovery interventions. Material and methods: This prospective, observational study investigated the impact of personalized recovery interventions on spinal instability, psychological distress, and quality of life in oncological patients with vertebral metastases. Results: The experimental group received tailored rehabilitation strategies, while the control group underwent standard oncological care. Spinal instability was assessed using the Spinal Instability Neoplastic Score (SINS), psychological distress was measured with the Hopelessness Depression Symptom Questionnaire (HDSQ), and quality of life was evaluated using the European Quality of Life-5 Dimensions (EQ-5D). The experimental group demonstrated significantly lower mean SINS scores, indicating reduced spinal instability, and lower HDSQ scores, suggesting decreased psychological distress. They also exhibited improvements in mobility, self-care, usual activities, and anxiety/depression dimensions of the EQ-5D. Furthermore, the experimental group had longer survival times, lower fracture rates, and reduced prevalence of osteoporosis, anemia, and vomiting. These findings underscore the potential benefits of integrating physical and psychological rehabilitation into routine oncological management. Conclusions: Personalized recovery interventions appear to enhance functional independence, emotional well-being, and overall quality of life in patients with vertebral metastases. Future research should focus on longitudinal, multicenter, randomized controlled trials to confirm these findings and further elucidate the complex interplay between spinal instability, psychological distress, and functional recovery. Full article

The objective of this study was to analyze treatment approaches and outcomes according to patients’ perspectives for patients with indeterminate spinal instability caused by neoplastic lesions. Data were collected from 31 patients with a total of 147 spinal neoplastic lesions, 29 of whom had lesions classified as indeterminate. These lesions were divided into two groups: the low indeterminate group (SINS 7–9) and the high indeterminate group (SINS 10–12). Conservative treatment was the primary approach (93%), resulting in improvement in 59% of cases, stability in 22%, and asymptomatic outcomes in 19%. No significant differences in self-reported outcomes were found between surgical and non-surgical treatments (p = 0.98, p = 0.18). Surgery was reserved for patients with severe pain or impending neurological compromise. Our findings suggest that conservative management is a viable option for most patients with indeterminate spinal instability caused by neoplastic lesions, provided pain and neurological stability are adequately controlled. Full article

Background: Although the Spinal Instability Neoplastic Score (SINS) is widely utilized to evaluate spinal instability, its prognostic value for survival in patients with cervical spinal metastases remains unclear. This study investigated the association between the SINS and survival outcomes in patients with metastatic cervical spine cancer. Methods: This retrospective cohort study included 106 patients who underwent surgery for metastatic cervical spine cancer at a single institution between 1995 and 2023. Patients were divided into two groups: high SINS (≥13) and low-to-moderate SINS (0–12). Overall survival (OS) was the primary outcome and was analyzed using Kaplan–Meier estimates and Cox regression. Secondary outcomes included changes in Eastern Cooperative Oncology Group Performance Status (ECOG-PS), operation time, estimated blood loss, and postoperative complications. Results: The median OS was significantly shorter in the high SINS group compared to the low-to-moderate SINS group (5.3 months versus 8.6 months; p = 0.023). A high SINS was independently associated with increased mortality risk (hazard ratio [HR], 1.959; 95% CI, 1.221–3.143; p = 0.005). Lung cancer (HR, 4.004; 95% CI, 1.878–8.535; p < 0.001) and rectal cancer (HR, 3.293; 95% CI, 1.126–9.632; p = 0.029) were predictive of worse survival, whereas postoperative chemotherapy (HR, 0.591; 95% CI, 0.381–0.917; p = 0.019) and radiotherapy (HR, 0.531; 95% CI, 0.340–0.827; p = 0.005) were associated with improved survival. Changes in the ECOG-PS and postoperative complication rates were not significantly different between the groups. Conclusions: A high SINS was associated with significantly shorter survival in patients with metastatic cervical spine cancer, reflecting both mechanical instability and tumor aggressiveness. Full article

Background/Objectives: Massive intraoperative blood loss (IBL) is one of the major complications in metastatic spinal tumor surgery (MSTS), and understanding the predictors of this risk is essential. This study aimed to determine the impact of the intratumoral flow void (IFV) observed on standard magnetic resonance imaging (MRI) and its association with IBL in palliative surgery for metastatic spinal tumors. Methods: This retrospective analysis included 88 palliative excisional surgeries performed at a single hospital between 2010 and 2024. Factors such as age, sex, body mass index, tumor location, histological tumor type, spinal instability neoplastic score, revised Tokuhashi score, preoperative radiation, presence of IFV, and IFV diameter were assessed in addition to surgical details such as the number of resected and instrumented vertebrae and surgical duration. Results: Of the 88 patients, 71 (80.7%) exhibited IFV, with a mean IFV diameter of 1.8 ± 1.3 mm. The univariate analysis identified a significant association between IBL and several factors, including the presence of IFV, IFV diameter, hypervascular tumor type, number of instrumented vertebrae, and surgical duration. The multivariate analysis indicated that IFV diameter had the highest standardized coefficient among the examined variables, suggesting its strong potential as a predictor of IBL. Conclusions: This is the first study to identify the IFV diameter as a critical and independent predictor of IBL in MSTS. IFV diameter, which can be easily assessed using standard MRI, should be considered in surgical planning to effectively manage bleeding. Full article

Background: One important determinant in choosing a treatment modality is spinal instability. Clear management guidelines are suggested for stable and unstable spinal metastatic lesions, but lesions in the intermediate instability category (SINS [spinal instability neoplastic score] score of 7–12) remain a clinical dilemma. This study aims to analyze the risk factors necessitating surgical intervention after radiotherapy (RT) in patients with those lesions. Methods: A multicenter cohort of 469 patients with spinal metastases of intermediate instability who received radiotherapy (RT) as the initial treatment between 2019 and 2021 were retrospectively enrolled. All patients were neurologically intact at the time of RT. According to the performance of surgical intervention after RT, various clinical and radiographic risk factors for surgical intervention were compared between surgery and non-surgery groups using uni- and multivariate analyses. A recursive partitioning analysis (RPA) was performed using significant determinants identified in multivariate analysis. Results: The mean age at the time of RT was 59.9 years and there were 198 females. The lung was the most common primary site. During the mean follow-up duration of 18.2 months, surgical treatment was required in 79 (17.9%) of patients. The most common surgical method was decompressive laminectomy with stabilization (62.0%), followed by vertebrectomy with stabilization (22.8%) and stabilization only (15.2%). The mean SINS for the total cohort was 9.0. Multivariate regression analyses revealed that the primary tumor site of the lung, liver, and kidney, higher Bilsky grades of ESCC, lytic bone lesions, and higher EQD2₁₀ were significant risk factors for surgical intervention after RT. Among them, Bilsky grade, primary tumor type of the lung, liver, and kidney, and EQD2₁₀ were the most important determinants for expecting the probability of surgical intervention on RPA. Conclusions: Surgical intervention was performed in 17.9% of patients with intermediate instability after RT as the initial treatment. The primary tumor site of the lung, liver, and kidney, higher Bilsky grade of ESCC, and EQD210 were the most important determinants for expecting the probability of surgical intervention. Therefore, the optimal treatment strategy needs to be devised by carefully evaluating the risk of surgical intervention. Full article

Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22–74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9–16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6–20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1–45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures. Full article

Background: Symptomatic spinal metastasis (SSM) decreases the activities of daily living (ADL) and quality of life of cancer patients. However, the risk factors for SSM onset remain unclear. This prospective cohort study aimed to statistically analyze the significant risk factors. Methods: From 2016 to 2018, 210 consecutive patients with spinal metastases were prospectively registered. Patients with SSM at the first consultation and those who were unable to be followed-up owing to poor general condition were excluded. The demographic factors (age, sex, primary cancer, performance status, and ADL), clinical factors (radiation therapy, chemotherapy, molecularly targeted drugs, and bone-modifying agents (BMAs)), and Spinal Neoplastic Instability Score (SINS) were evaluated. Multivariate analysis was performed to identify the risk factors for SSM onset. Furthermore, the threshold was calculated from the receiver operating characteristic curve using the Youden index. Results: Thirty-nine patients who presented with SSM at the first consultation and 43 patients who were unable to be followed-up owing to poor general condition were excluded. Finally, 128 asymptomatic patients were included. Thirty-seven patients (28.9%) developed SSM during the follow-up period. The total SINS (OR: 1.739; 95% CI: 1.345–2.250) was identified as the most significant factor. The cut-off value of the SINS was 9.5 (sensitivity: 67.6%; specificity: 83.5%). Twenty-five (62.5%) of the forty patients with a SINS ≥ 10 developed SSM within a mean of 5.5 months (95% CI: 1.17–9.83). Furthermore, all patients with a SINS ≥ 13 developed SSM (n = 5) within a mean of 1.37 months (95% CI: 0.0–3.01). Conclusions: This study identified the significant risk factors for SSM onset and the threshold of the SINS. If long-term survival is expected, patients with a SINS ≥ 10 should be considered for intervention to prevent SSM. Full article

Currently, there is uncertainty about the predictive factors for metastatic epidural spinal cord compression (MESCC) and consecutive symptomatology in tumor patients. Prognostic algorithms for identifying patients at risk for paralysis are missing. The influence of the pathologic fracture on the patient’s symptoms is widely discussed in the literature and we hypothesize that pathologic fractures contribute to spinal cord compression and are therefore predictive of severe paralysis. We tested this hypothesis in 136 patients who underwent surgery for spinal metastases. The most common primary cancers were prostate (24.3%, n = 33), breast (11.0%, n = 15), lung (10.3%, n = 14), and cancer of unknown primary (10.3%, n = 14). MESCC primarily affected the thoracic (77.2%, n = 105), followed by the lumbar (13.2%, n = 18) and cervical (9.6%, n = 13) spine. Pathologic fractures occurred in 63.2% (n = 86) of patients, mainly in osteolytic metastases. On the American spinal injury association (ASIA) impairment scale (AIS), 63.2% (n = 86) of patients exhibited AIS grade D and 36.8% (n = 50) AIS grade C-A preoperatively. The presence of a pathologic fracture alone did not predict severe paralysis (AIS C-A, p = 0.583). However, the duration of sensorimotor impairments, patient age, spinal instability neoplastic score (SINS), and the epidural spinal cord compression (ESCC) grade together predicted severe paralysis (p = 0.006) as did the ESCC grade 3 alone (p = 0.028). This is in contrast to previous studies that stated no correlation between the degree of spinal cord compression and the severity of neurologic impairments. Furthermore, the high percentage of pathologic fractures found in this study is above previously reported incidences. The risk factors identified can help to predict the development of paralysis and assist in the improvement of follow-up algorithms and the timing of therapeutic interventions. Full article

(1) Background: Plasma cell neoplasia can be separated into independent subtypes including multiple myeloma (MM) and solitary plasmacytoma of the bone (SBP). The first clinical signs patients present with are skeletal pain, most commonly involving ribs and vertebrae. (2) Methods: Retrospective analysis of 114 patients (38 female, 76 male) receiving spinal surgery from March 2006 until April 2020. Neurological impairments and surgical instability were the criteria for intervention in this cohort. Analysis was based on demographic data, Spinal Instability Neoplastic Score (SINS), location of the lesion, spinal levels of tumor involvement, surgical treatment, histopathological workup, adjuvant therapy, functional outcome, and overall survival (OS). (3) Results: The following surgical procedures were performed: posterior stabilization only in 9 patients, posterior stabilization and decompression without vertebral body replacement in 56 patients, tumor debulking and decompression only in 8 patients, anterior approach in combined approach without vertebral body replacement and without biopsy and/or without kyphoplasty in 33 patients, 3 patients received biopsies only, and 5 patients received kyphoplasty only. The histopathology diagnoses were MM in 94 cases and SBP in 20 cases. Median OS was 72 months (53.4–90.6 months). Preoperative KPSS was 80% (range 40–100%), the postoperative KPSS was 80% (range 50–100%). (4) Conclusions: Surgery for patients with plasma cell neoplasia is beneficial in case of neurological impairment and spinal instability. Moreover, we were able to show that patients with MM and a low number of spinal levels to be supplied have a better prognosis as well as a younger age at the time of the surgical intervention. Full article

Background: Adequate assessment of spinal instability using the spinal instability neoplastic score (SINS) frequently guides surgical therapy in spinal epidural osseous metastases and subsequently influences neurological outcome. However, how to surgically manage ‘impending instability’ at SINS 7–12 most appropriately remains uncertain. This study aimed to evaluate the necessity of spinal instrumentation in patients with SINS 7–12 with regards to neurological outcome. Methods: We screened 683 patients with spinal epidural metastases treated at our interdisciplinary spine center. The preoperative SINS was assessed to determine spinal instability and neurological status was defined using the Frankel score. Patients were dichotomized according to being treated by instrumentation surgery and neurological outcomes were compared. Additionally, a subgroup analysis of groups with SINS of 7–9 and 10–12 was performed. Results: Of 331 patients with a SINS of 7–12, 76.1% underwent spinal instrumentation. Neurological outcome did not differ significantly between instrumented and non-instrumented patients (p = 0.612). Spinal instrumentation was performed more frequently in SINS 10–12 than in SINS 7–9 (p < 0.001). The subgroup analysis showed no significant differences in neurological outcome between instrumented and non-instrumented patients in either SINS 7–9 (p = 0.278) or SINS 10–12 (p = 0.577). Complications occurred more frequently in instrumented than in non-instrumented patients (p = 0.016). Conclusions: Our data suggest that a SINS of 7–12 alone might not warrant the increased surgical risks of additional spinal instrumentation. Full article

Background and Objectives: There have been numerous advances in spine surgery for metastatic spinal tumors, and minimally invasive spine stabilization (MISt) is becoming increasingly popular in Japan. MISt is a minimally invasive fixation procedure that temporarily stabilizes the spine, thereby reducing pain, preventing pathological fractures, and improving activities of daily living at an early stage. MISt may be useful given the recent shift toward outpatient cancer treatment. Materials and Methods: This study enrolled 51 patients with metastatic spinal tumors who underwent surgery using MISt between December 2013 and October 2020. The Spinal Instability Neoplastic Score, an assessment of spinal instability, was used to determine the indication for surgery, and the Epidural Spinal Cord Compression scale was used for additional decompression. Results: The patients comprised 34 men and 17 women, and the mean age at surgery was 68.9 years. The mean postoperative follow-up period was 20.8 months, and 35 of 51 patients (67%) had died by the last survey. The mean operative time was 159.8 min, mean blood loss was 115.7 mL, and mean time to ambulation was 3.2 days. No perioperative complications were observed, although two patients required refixation surgery. Preoperatively, 37 patients (72.5%) were classified as Frankel grade E. There were no cases of postoperative exacerbation, and six patients showed improvement of one or more Frankel grades after surgery. The median duration of patient survival was about 22.0 months. Patients with breast, prostate, renal, and thyroid cancers had a good prognosis, whereas those with gastrointestinal and head and neck cancers had a poor prognosis. Conclusions: MISt can benefit patients who are ineligible for conventional, highly invasive surgery and is also suitable because cancer treatment is increasingly performed on an outpatient basis. Furthermore, choosing the right surgery for the right patient at the right time can significantly affect life expectancy. Full article

Major progress has been achieved to treat cancer patients and survival has improved considerably, even for stage-IV bone metastatic patients. Locomotive health has become a crucial issue for patient autonomy and quality of life. The centerpiece of the reflection lies in the fracture risk evaluation of bone metastasis to guide physician decision regarding physical activity, antiresorptive agent prescription, and local intervention by radiotherapy, surgery, and interventional radiology. A key mandatory step, since bone metastases may be asymptomatic and disseminated throughout the skeleton, is to identify the bone metastasis location by cartography, especially within weight-bearing bones. For every location, the fracture risk evaluation relies on qualitative approaches using imagery and scores such as Mirels and spinal instability neoplastic score (SINS). This approach, however, has important limitations and there is a need to develop new tools for bone metastatic and myeloma fracture risk evaluation. Personalized numerical simulation qCT-based imaging constitutes one of these emerging tools to assess bone tumoral strength and estimate the femoral and vertebral fracture risk. The next generation of numerical simulation and artificial intelligence will take into account multiple loadings to integrate movement and obtain conditions even closer to real-life, in order to guide patient rehabilitation and activity within a personalized-medicine approach. Full article

This study examined changes in the quality of life (QOL), as well as the factors affecting QOL, among patients with painful spinal bone metastases without paralysis for 1 month after radiotherapy. Methods: This study included 79 participants (40 male and 39 female; median age, 65 (42–88) years) who had undergone radiotherapy for painful spinal bone metastases without paralysis. Patients’ age, sex, activities of daily living (Barthel index), pain, spinal instability (spinal instability neoplastic score [SINS]), and QOL (EORTC QLQ-C30) were investigated. Results: Having an unstable SINS score was a positive factor for global health status (p < 0.05). The improvement in activities of daily living and response to pain were positive factors for physical function (p < 0.05). A positive effect on emotional function was confirmed among female patients (p < 0.05). Conclusion: Engaging in rehabilitation along with radiotherapy leads to improvements in QOL for patients with spinal bone metastases. Full article