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BACKGROUND CONTEXT Surgical decompression and stabilization in the setting of spinal metastasis is performed to relieve pain and preserve functional status. These potential benefits must be weighed against the risks of perioperative morbidity and mortality. Accurate prediction of a patient's postoperative survival is a crucial component of patient counseling. PURPOSE To externally validate the SORG machine learning algorithms for prediction of 90-day and 1-year mortality after surgery for spinal metastasis. STUDY DESIGN/SETTING Retrospective, cohort study PATIENT SAMPLE Patients 18 years or older at a tertiary care medical center treated surgically for spinal metastasis OUTCOME MEASURES Mortality within 90 days of surgery, mortality within 1 year of surgery METHODS This is a retrospective cohort study of 298 adult patients at a tertiary care medical center treated surgically for spinal metastasis between 2004 and 2020. Baseline characteristics of the validation cohort were compared to the derivation cohort for the SORG algorithms. The following metrics were used to assess the performance of the algorithms: discrimination, calibration, overall model performance, and decision curve analysis. RESULTS Sixty-one patients died within 90 days of surgery and 133 died within 1 year of surgery. The validation cohort differed significantly from the derivation cohort. The SORG algorithms for 90-day mortality and 1-year mortality performed excellently with respect to discrimination; the algorithm for 1-year mortality was well-calibrated. At both postoperative time points, the SORG algorithms showed greater net benefit than the default strategies of changing management for no patients or for all patients. CONCLUSIONS With an independent, contemporary, and geographically distinct population, we report successful external validation of SORG algorithms for preoperative risk prediction of 90-day and 1-year mortality after surgery for spinal metastasis. By providing accurate prediction of intermediate and long-term mortality risk, these externally validated algorithms may inform shared decision-making with patients in determining management of spinal metastatic disease.

Metastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life.The purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD.This was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD).All patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study.Mortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed.International Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts - those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared.The number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85-3.63, p.0001), blood transfusion (OR=2.93, 95% CI: 2.66-3.23, p.0001), any complication (OR=1.24, 95% CI: 1.18-1.31, p.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41-1.61, p.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p.0001) and cost ($49,421.75 vs. $26,190.37, p.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68-2.96, p.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20-2.58, p.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27-2.06, p.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53-0.96, p=.026).The number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.

Background Context: Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients’ survival. Purpose: We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients’ postoperative survival, as well as described neurologic changes after surgery. Study Design: Retrospective cohort study. Patient Sample: We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers. Outcome Measures: Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death. Methods: We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival. Results: From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49–0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00–2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97–2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02–2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06–5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07–2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17–1.68, p

BACKGROUND CONTEXT Oncologic resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, executing a meticulously drafted plan sometimes fails. PURPOSE The goal of this study was to utilize prospective multicenter data to determine how successful experienced surgical teams are at achieving planned surgical margins and how successful surgeons are in assessing tumor margins intraoperatively. The secondary objective was to identify factors that are associated with successful execution of the planned margins. STUDY DESIGN/SETTING This study was part of a multicenter international prospective registry for the management and outcomes of primary tumors of the spine called Primary Tumor Research and Outcomes Network (PTRON, ClinicalTrials.gov: NCT02790983). PTRON was designed and led by the AO Spine Knowledge Forum Tumor and has established an international network of 16 spine oncology centers from North America, Europe, and Asia that are dedicated to prospective research of patients diagnosed with a primary tumor of the spine. OUTCOME MEASURES Using this registry, we compared (1) planned surgical margin and (2) intraoperative assessment of the margin by the surgeon to the postoperative assessment of the margin by the pathologist. Planned and intraoperative margin assessments by the surgeon were assessed and recorded in the PTRON database in five categories: (1) intralesional; (2) intralesional with planned focal transgression; (3) marginal; (4) wide with marginal at dura, and (5) wide. The pathologist's assessment was documented in four categories for overall margin, at soft tissue, at bone, and at dura: (1) intralesional; (2) intralesional with planned focal transgression; (3) marginal; and (4) wide. The primary endpoints of this analysis were to compare (1) the planned surgical margin and (2) intraoperative assessment of the margin by the surgeon to the postoperative assessment of the margin by the pathologist. For the first endpoint, success was defined as achievement of planned surgical margins or better as confirmed by pathologist assessment. For the second endpoint, success was defined by appropriate intraoperative assessment of the margin by the surgeon when compared to histologic assessment. METHODS Univariate analyses were used to assess factors associated with successful execution of the planned resection. RESULTS A total of 300 patients from 16 centers located in North America, Europe and Asia were included for analysis. Median age was 46.0 years (IQR 27.0 – 61.5). The majority of patients were male (63.0%). Successful achievement of planned margins was attained in 224 patients (74.7%). Overall, marginal or wide margins were attained in 261 patients (87.0%). Surgeon's perception of the margins achieved intraoperatively was correctly determined in 239 patients (79.7%) compared to pathologist assessment. Margins identified as marginal or wide were adequately evaluated intraoperatively as such in 261 patients (87.0%). On univariate analysis, no factors had a statistically significant association with the achievement of successful margins. Conclusions In high volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with expected success rates in order to optimize patient management and surgical decision-making. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

General questionnaires are often used to assess quality of life in patients with spine metastases, although a disease-specific survey did not exist until recently. The Spine Oncology Study Group has developed an outcomes questionnaire (SOSG-OQ) to measure quality of life in these patients. However, a scoring system was not developed, and the questionnaire was not validated in a group of patients, nor was it compared with other general quality of life questionnaires such as the EuroQol 5 Dimensions (EQ-5D) questionnaire.Our primary null hypothesis is that there is no association between the SOSG-OQ and EQ-5D. Our secondary null hypothesis is that there is no difference in coverage and internal consistency between the SOSG-OQ and EQ-5D. We also assess coverage, consistency, and validity of the domains within the SOSG-OQ.A survey study from a tertiary care spine referral center was used for this study.The patient sample consisted of 82 patients with spine metastases, myeloma, or lymphoma.The SOSG-OQ (27 questions, 6 domains) score ranges from 0 to 80, with a higher score indicating worse quality of life. The EQ-5D (5 questions, 5 domains) index score ranges from 0 to 1, with a higher score indicating better quality of life.The association between the SOSG-OQ and EQ-5D index score was assessed using the Spearman rank correlation. Instrument coverage and precision were assessed by determining item completion rate, median score with range, and floor and ceiling effect. Internal consistency was assessed using Cronbach alpha. Multitrait analysis and exploratory factor analysis were used to analyze properties of the individual domains in the SOSG-OQ.The Spearman rank correlation between the SOSG-OQ and EQ-5D questionnaire was high (r=-0.83, p.001). Internal consistency of the SOSG-OQ (0.92, 95% CI: 0.89-0.94) was higher as compared to the internal consistency of the EQ-5D (0.73, 95% CI: 0.63-0.84; p.001). The SOSG-OQ score had no floor or ceiling effect indicating good coverage (median 30, range 3-64), whereas the EQ-5D had a ceiling effect of 10% (median 0.71, range 0.05-1).In conclusion, our study proposes a scoring methodology-after reversing four inversely scored items-for the SOSG-OQ and shows that the questionnaire is a valid tool for the assessment of quality of life in patients with metastatic spine disease. The SOSG-OQ is superior to the EQ-5D in terms of coverage and internal consistency but consists of more questions.

Background Context Patient-reported outcomes are becoming increasingly important when investigating results of patient and disease management. In sacral tumor, the symptoms of patients can vary substantially; therefore, no single questionnaire can adequately account for the full spectrum of symptoms and disability. Purpose The purpose of this study is to analyze redundancy within the current sacral tumor survey and make a recommendation for an updated version based on the results and patient and expert opinions. Study Design/Setting A survey study from a tertiary care orthopedic oncology referral center was used. Patient Sample The patient sample included 70 patients with sacral tumors (78% chordoma). Outcome Measures The following 10 questionnaires included in the current sacral tumor survey were evaluated: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Item short form, PROMIS Pain Intensity short form, PROMIS Pain Interference short form, PROMIS Neuro-QOL v1.0 Lower Extremity Function short form, PROMIS v1.0 Anxiety short form, the PROMIS v1.0 Depression short form, the International Continence Society Male short form, the Modified Obstruction-Defecation Syndrome questionnaire, the PROMIS Sexual Function Profile v1.0, and the Stoma Quality of Life tool. Methods We performed an exploratory factor analysis to calculate the possible underlying latent traits. Spearman rank correlation coefficients were used to measure to what extent the questionnaires converged. We hypothesized the existence of six domains based on current literature: mental health, physical health, pain, gastrointestinal symptoms, sexual function, and urinary incontinence. To assess content validity, we surveyed 32 patients, 9 orthopedic oncologists, 1 medical oncologist, 1 radiation oncologist, and 1 orthopedic oncology nurse practitioner with experience in treating sacral tumor patients on the relevance of the domains. Results Reliability as measured by Cronbach alpha ranged from 0.65 to 0.96. Coverage measured by floor and ceiling effects ranged from 0% to 52% and from 0% to 30%, respectively. Explanatory factor analysis identified three traits to which the questionnaires that were expected to measure a similar construct correlated the most: mental health, physical function, and pain. Content validity index demonstrated low disagreement among patients (range: 0.10–0.18) and high agreement among physicians (range: 0.91–1.0) on the relevance of the proposed domains. Social health was identified by 50% of the commenting patients as an important yet missing domain. Conclusions The current sacral tumor survey is incomplete and time-consuming, and not all surveys are appropriate for the sacral tumor population. Our recommended survey contains less than half the questions and includes the newly recognized social health domain.

Background Context Perioperative allogeneic blood transfusions have been associated with decreased survival after surgical resection of primary and metastatic cancer. Studies investigating this association for patients undergoing resection of bone metastases are scarce and controversial. Purpose We assessed (1) whether exposure to perioperative allogeneic blood transfusions was associated with decreased survival after surgery for spinal metastases and (2) if there was a dose-response relationship per unit of blood transfused. Additionally, we explored the risk factors associated with survival after surgery for spinal metastases. Study Design/Setting This is a retrospective cohort study from two university medical centers. Patient Sample There were 649 patients who had operative treatment for metastatic disease of the spine between 2002 and 2014. Patients with lymphoma or multiple myeloma were also included. We excluded patients with a revision procedure, kyphoplasty, vertebroplasty, and radiosurgery alone. Outcome Measures The outcome measure was survival after surgery. The date of death was obtained from the Social Security Death Index and medical charts. Methods Blood transfusions within 7 days before and 7 days after surgery were considered perioperative. A multivariate Cox proportional hazard model was used to assess the relationship between allogeneic blood transfusion as exposure versus non-exposure, and subsequently as continuous value; we accounted for clinical, laboratory, and treatment factors. Results Four hundred fifty-three (70%) patients received perioperative blood transfusions, and the median number of units transfused was 3 (interquartile range: 2–6). Exposure to perioperative blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.80–1.31; p=.841). Neither did we find a dose-response relationship (HR: 1.01; 95% CI: 0.98–1.04; p=.420). Other factors associated with worse survival were older age, more severe comorbidity status, lower preoperativehemoglobin level, higher white blood cell count, higher calcium level, primary tumor type, previous systemic therapy, poor performance status, presence of lung, liver, or brain metastasis, and surgical approach. Conclusions Perioperative allogeneic blood transfusions were not associated with decreased survival after surgery for spinal metastases. More liberal transfusion policies might be warranted for patients undergoing surgery for spinal metastasis, although careful consideration is needed as other complications may occur.