Prognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor

doi:10.1016/j.wneu.2018.01.092

World Neurosurgery

Volume 113, May 2018, Pages e20-e28

https://doi.org/10.1016/j.wneu.2018.01.092 Get rights and content

Highlights

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An extended retrospective database comprised 337 patients who underwent spinal surgery for spinal metastases.
•
Statistical analysis was done to examine risk factors of surgical complications and prognostic factors of OS.
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Age, motor disorder, Frankel grade, KPS, type of primary tumor, and presence of internal metastasis significantly affect OS.
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Complications can be predicted by performance status, type of tumor, affected vertebral levels, and type of intervention.

Objective

Oncologic treatments increase the incidence of spinal metastases. Surgical treatment of spinal metastases results in a high complication rate, which must set against the expected benefits. The aim of this article was to study the effect of several prognostic factors on surgical complications and survival time using an extended database of patients with spinal metastases.

Methods

This retrospective study comprised 337 patients with spinal metastases who were surgically treated between 2008 and 2015. Demographic and clinical features, oncologic histories, surgical interventions, and end results were collected. Descriptive statistical methods were used to analyze the cohort of patients. Kaplan-Meier formula and log-rank test were used to examine overall survival times.

Results

Median overall survival time was 222 days (range, 175–274 days). Age, preoperative motor disorders, preoperative Frankel grade categories, Karnofsky performance scale, type of primary tumor, and presence of internal metastasis had a significant negative effect on overall survival. Complications such as bleeding or need for intensive care could be predicted preoperatively based on preoperative performance status, type of primary tumor, affected vertebral levels, and type of surgical interventions.

Conclusions

Spinal metastatic disease is a challenging surgical problem. If the exact prognostic factors are known preoperatively, surgical outcome and overall survival can be predicted more precisely. Our results could provide a basis for a future multicenter prospective study to determine the best treatment protocol for patients with spinal metastases.

Introduction

Longer life expectancy of patients with cancer and successful oncologic treatments have resulted in an increased incidence of spinal metastases.1, 2, 3, 4 Spinal metastases can be expected in 70% of patients with a cancer diagnosis, and neurologic symptoms related to spinal cord compression may develop in 10%.⁵ The main goals of surgical treatment should be to improve mechanical stability, decompress neural structures, relieve neurologic symptoms, and improve quality of life; however, most of the underlying cancer types and stages carry dismal prognoses.2, 6 Surgical treatment of spinal metastases results in a complication rate of 20%–30%, which must be considered against the expected benefits.2, 7 If the exact risk and complication factors are known preoperatively, surgical outcome can be predicted more precisely. Scoring systems, such as Tokuhashi,8, 9, 10 Tomita,¹¹ Bauer,12, 13 and Linden¹⁴ systems, are widely used in clinical practice to offer the best surgical strategy based on the patient's prognostic factors. Using an extended database of patients who underwent surgical interventions because of spinal metastases, the aim of this article was to study the effect of the risk factors of 4 prognosis scoring systems on the survival time of patients with metastatic spinal tumors. Furthermore, we aimed to investigate the prediction ability of scoring systems for prognosis and to possibly evaluate new risk factors to extend the prediction ability of various prognostic systems in the future. Correlating risk factors with the main surgical complications were also examined.

Section snippets

Patient Database

We created a retrospective database of 337 patients who underwent spinal surgery for spinal metastases at the National Institute of Clinical Neuroscience, Department of Neurosurgery, Semmelweis University, Budapest, Hungary, between 2008 and 2015. Surgical intervention was the only criterion of admission for the study. Of the 382 interventions identified in the inquiry, 337 patient histories were compiled; 38 patients had records with multiple surgical interventions (31 patients with 2

Survival Data and Rate of Complications

We identified 337 patients, 199 (59.1%) men and 138 (40.9%) women, with a mean age of 63 ± 12 years (range, 15–88 years). OS was calculated by the Kaplan-Meier formula (Table 5). Median OS (amount of time when 50% of the patients have died) was 222 days; the 95% confidence interval ranged from 175 to 274 days. Because some patients were alive at the time of data taking, we provide the restricted mean (upper limit = 2739 days) for the OS time as 660.3 days (with SE 56.7 days). The Kaplan-Meier

Discussion

Modern oncologic treatment and developing surgical techniques extend the life expectancy of patients with cancer, allowing malignant mutations to eventually grow and metastasize.2, 11, 16 The spinal column is the most frequently affected part of the skeletal system in terms of metastasis.16, 17, 18 Owing to the oncologic nature of the disease, surgery alone is not sufficient to determine the most effective treatment method. A more personalized, multifactorial approach is necessary to provide a

Conclusions

The aim of this study was to analyze an extended database of patients with spinal metastases who underwent surgical interventions. Our investigation mainly focused on risk factors for surgical complications and prognostic factors of OS time. Age, preoperative motor disorders, preoperative Frankel grade categories, KPS, type of primary tumor, and presence of internal metastasis have a significant negative effect on OS. Complications such as bleeding or need for intensive care could be predicted

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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).
A National Surgical Quality Improvement Program Analysis of Postoperative Major and Minor Complications in Patients with Spinal Metastatic Disease
2020, World Neurosurgery
Citation Excerpt :
Patil et al.9 extracted a group of >26,000 patients from the National Inpatient Sample who underwent surgery for spinal metastasis, showing that older age was associated with both an increased postoperative morbidity and mortality with OR increasing with age (1.1 for 45–64 years, 1.5 for 65–84 years, and 2.1 for >84 years). Age was also associated with postoperative complications in various single-center studies.10,24 On the other hand, a correlation between age and risk for complications was not found by other investigators.14,15,23-27
Major complications after spine metastasis surgery are prioritized in the literature with little consideration of the more frequent minor events such as pneumonia or urinary tract infection. We analyzed incidence and risk factors of postsurgical complications in patients with spinal metastasis extracted from the National Surgical Quality Improvement Program (NSQIP). We also developed a useful predictive model to estimate the probability of occurrence of complications.
A total of 1176 patients diagnosed with spinal metastasis were extracted from NSQIP. Variables screened included age, sex, tumor location, patient’s functional status, comorbidities, laboratory values, and case urgency. Two multivariate logistic regression models were designed to evaluate risk factors and likelihood of event occurrence.
Minor events occurred twice as frequently compared with major complications (36% vs. 18% of patients). The most common major event was death (10%); the most frequent minor event was need for postoperative transfusion (29.4%). In the multivariate analysis, elderly age, emergency case, preoperative leukocytosis, and smoking status retained significance for major complications; American Society of Anesthesiologists classes 4–5, low hematocrit levels, and intradural extramedullary location of the tumor retained significance for minor complications. The predictive models designed explained 72% of the variability in major complications occurrence and 67% for minor events.
Smoking status and emergent surgery were found to be the strongest independent predictors of major complications, whereas higher American Society of Anesthesiologists class showed a greater association with minor events. The predictive models produced can be a useful aid for surgeons to identify those patients who are at greater risk of developing postoperative adverse events.
Outcomes in Patients with Spinal Metastases Managed with Surgical Intervention
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Surgical strategy for metastatic spinal tumor patients with surgically challenging situation
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Identifying new predictive factors for survival after surgery for spinal metastases: an exploratory in-depth retrospective analysis
2022, Acta Clinica Belgica: International Journal of Clinical and Laboratory Medicine
Survival, fusion, and hardware failure after surgery for spinal metastatic disease
2021, Journal of Neurosurgery: Spine

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: Conflict of interest statement: This project received partial funding from the Novo Nordisk Foundation Interdisciplinary Synergy Programme (P. Pollner, Grant NNF15OC0016584) and EFOP-3.6.3-VEKOP-16-2017-00009 scholarship (G. Czigléczki).

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Original ArticlePrognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor

Highlights

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patient Database

Survival Data and Rate of Complications

Discussion

Conclusions

Orthop Traumatol Surg Res

Spine J

Int J Radiat Oncol Biol Phys

Orthop Clin North Am

Cancer undefeated

N Engl J Med

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Eur Spine J

The surgical treatment of metastatic disease of the spine

Radiother Oncol

Metastatic spinal tumors

Neurosurg Focus

Evaluation and treatment of spinal metastases: an overview

Neurosurg Focus

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

Complication, survival rates, and risk factors of surgery for metastatic disease of the spine

Spine (Phila Pa 1976)

Scoring system for prediction of metastatic spine tumor prognosis

World J Orthop

A scoring system for preoperative evaluation of the prognosis of metastatic spine tumor (a preliminary report)

Nihon Seikeigeka Gakkai Zasshi

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

Spine (Phila Pa 1976)

Surgical strategy for spinal metastases

Spine (Phila Pa 1976)

Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients

Acta Orthop Scand

Original Article
Prognostic Factors of Surgical Complications and Overall Survival of Patients with Metastatic Spinal Tumor