Non-operative management of spinal metastases: A prognostic model for failure
Prognosis; Survival; Surgery; Spinal metastases; Ambulatory function; Non-operative treatment
OBJECTIVES: To describe patient-specific characteristics associated with non-operative failure leading to surgery. PATIENTS AND METHODS: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. RESULTS: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). CONCLUSION: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.
Schoenfeld Andrew J; Schwab Joseph H; Ferrone Marco L; Blucher Justin A; Balboni Tracy A; Barton Lauren B; Chi John H; Kang James D; Losina Elena; Katz Jeffrey N
Clinical Neurology And Neurosurgery
2019
2019-11-04
Journal Article
<a href="http://doi.org/10.1016/j.clineuro.2019.105574" target="_blank" rel="noreferrer noopener">10.1016/j.clineuro.2019.105574</a>
PMID: 31707291
Design of the Prospective Observational Study of spinal metastasis Treatment (POST)
decision making; Spinal metastases; NESMS; POST; predictive score
BACKGROUND CONTEXT: There are several prognostic scores available that intend to inform decision making for patients with spinal metastases. Many of these have not been found to reliably predict survival across the continuum of care. Recently, our group developed the New England Spinal Metastasis Score (NESMS). While the NESMS demonstrated many of the necessary attributes of a useful prediction tool, it has yet to be validated prospectively. PURPOSE: To describe the Prospective Observational study of Spinal metastasis Treatment (POST). This investigation examined the performance of the NESMS, compared its predictive capacity to other scoring systems and determined its ability to identify patients who benefit the most from surgery. STUDY DESIGN: Prospective observational study at two medical centers. PATIENT SAMPLE: Patients age 18 and older with spinal metastases involving the spine. OUTCOME MEASURES: Survival, post-treatment morbidity and health related quality of life (HRQL) outcomes. METHODS: The POST study assessed patients at baseline and at 1-month, 3-month, 6-month and 12-month time-points. During the baseline assessment patient demographics, past medical history and assessment of co-morbidities, surgical history, primary tumor histology and ambulatory status were recorded along with the designated treatment strategy (e.g. operative or non-operative). The NESMS and other predictive scores for each patient were calculated based on baseline data. Study-specific surveys administered at all time-points consisted of the EuroQuol 5-Dimension and Short-Form (SF)-12, Visual Analog Scale (VAS) for pain and PROMIS assessment of global health. RESULTS: Two hundred patients were enrolled in POST from 2017-2019. Patients were followed to one of the two pre-determined study end-points (i.e. mortality, or completion of the 12-month follow-up). Survival was considered the principle dependent variable. Post-treatment morbidity and HRQL outcomes were considered secondarily. Analyses, by aim, relied on Cox proportional hazards regression, repeated measures logistic regression, propensity score matching and multivariable logistic regression. CONCLUSION: The POST's findings are anticipated to provide evidence regarding the prognostic capabilities of the NESMS as well as that of other popular grading schemes for survival, post-treatment complications and physical as well as mental function.
Schoenfeld Andrew J; Blucher Justin A; Barton Lauren B; Schwab Joseph H; Balboni Tracy A; Chi John H; Shin John H; Kang James D; Harris Mitchel B; Ferrone Marco L
The Spine Journal: Official Journal Of The North American Spine Society
2019
2019-11-08
Journal Article
<a href="http://doi.org/10.1016/j.spinee.2019.10.021" target="_blank" rel="noreferrer noopener">10.1016/j.spinee.2019.10.021</a>
PMID: 31712164
Validating the Stopping Opioids after Surgery (SOS) score for sustained postoperative prescription opioid use in spine surgical patients.
Opioid dependence; Spine surgery; Prediction; Anterior cervical discectomy and fusion; Lumbar disc herniation; Risk score
BACKGROUND CONTEXT: The opioid epidemic has increased scrutiny of health-care practices and care episodes, such as surgery, that increase the risk of opioid dependence. The Stopping Opioids after Surgery (SOS) score to predict sustained prescription opioid use was previously developed within a population of patients receiving general surgery, orthopedic, and urologic procedures. Notably, the performance for this score has not been assessed in a spine surgical cohort. PURPOSE: We sought to validate the SOS score in a series of patients undergoing cervical and lumbar spine surgery, including inpatient and outpatient cohorts. STUDY DESIGN/SETTING: Retrospective review at two academic medical centers and three community hospitals. OUTCOME MEASURES: Sustained prescription opioid use was defined as opioid prescription without interruption for 90 days or longer following surgery. METHODS: The performance of the SOS score was assessed in the study population by calculating the c-statistic, receiver-operating curve, and observed rates of sustained prescription opioid use. RESULTS: Among 7,027 patients included in this study, 2,374 (33.8%) underwent anterior cervical discectomy and fusion and 4,653 (66.2%) underwent surgery for lumbar disc herniation. The median age was 46 (interquartile range=38.0-53.5). Overall, 604 patients (8.6%) had prolonged opioid prescription. The c-statistic of the risk score was 0.764. The sensitivity of the score at the low risk cutoff of 30 was 0.72. At the high-risk cutoff of 60, the specificity was 0.99. The observed risk (95% confidence interval) of prolonged opioid prescription was 3.6% (3.1-4.2) in the low-risk group (scores <30), 17.2% (15.6-18.7) in the intermediate-risk group (scores 30-60), and 46.0% (36.2-55.9) in the high-risk group (scores >60). CONCLUSIONS: We have validated the use of a clinically relevant bedside risk score for sustained prescription opioid use after spine surgery. The score's ease of use, combined with its exceptional performance, renders it a valuable tool for spine care providers in counseling patients and determining appropriate postdischarge management to prevent sustained opioid use.
Karhade Aditya V; Chaudhary Muhammad Ali; Bono Christopher M; Kang James D; Schwab Joseph H; Schoenfeld Andrew J
The Spine Journal: Official Journal Of The North American Spine Society
2019
2019-10
Journal Article
<a href="http://doi.org/10.1016/j.spinee.2019.05.001" target="_blank" rel="noreferrer noopener">10.1016/j.spinee.2019.05.001</a>
PMID: 31078697