Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise? Can we predict which patients will benefit from surgery?. Retrospective review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Poor correlation with Tomita scores (-0.25) & Tokuhashi scores (0.24) to predict survival. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The predictive scoring systems remain unreliable making it difficult to select those patients who would benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise?. Do patients require surgery or are the majority adequately treated by oncologists?. Review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones, and it is now standard practice that long bones with metastases at risk of fracture are treated with prophylactic internal fixation. The spine is the most common site of skeletal metastases, with spinal metastases present in up to 36% of patients with terminal cancer. A pathological fracture through a vertebral body can result in paralysis, incontinence and severe pain. However, there is no equivalent of the Mirels’ scoring system to aid the spinal surgeon in determining the probability of an impending spinal fracture.

A weighted scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body. This system analyzes and combines four magnetic resonance (MR) risk factors into a single score.

Methods: A retrospective analysis of 100 vertebral body metastatic lesions was carried out. The original MR scans were scored, and the subsequent imaging was used to identify which vertebral body lesions fractured. Patients with no subsequent imaging within 12 months were excluded.

Results: Twenty of the 100 lesions fractured within 12 months. A mean score of 0.64 was identified in the non-fracture group, where as the fracture group had a mean score of 6.80. The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 3, so did the percentage risk of fracture (sensitivity 90%, specificity 91%).

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 2 or less can be left untreated, while lesions with scores of 3 or higher should be considered for prophylactic balloon kyphoplasty.

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years). Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted

Introduction. Treatment of spinal metastatic disease has evolved with the advent of advanced interventional, surgical and radiation techniques. Spinal Oligometastatic disease is a low volume disease state where en bloc resection of the tumour, based on oncological principles, can achieve maximum local control (MLC). Hybrid therapy incorporating Separation surgery (>2mm clearance of the thecal sac) and Stereotactic Ablative Radiotherapy (SABR) offer an alternative approach to achieving MLC. Hybrid therapy is also a viable option in patients eligible for SBRT who have failed conventional radiation therapy. En-bloc surgery may be a suitable option for those patients who are ineligible for or have failed SBRT. A multidisciplinary approach is particularly important in the decision-making process for these patients. Metal free instrumentation is aiding the optimization of these surgeries. The authors present a supra-regional centre's experience in managing spinal oligometastases. Methods. Retrospective review of oligometastatic spinal disease at a supra-regional centre between 2017 and 2021. Demographics, operative course, complications and Instrument type are examined. Results. Demographics: 24 patients with mean age 53.8y (range 12–77), 44% (40y–59y), 40% (60y–69y); 51% Male. Histology: Breast, Renal and Sarcoma accounted for 16.7% each; Thyroid, Prostate and Chordoma accounted for 8.3% each. Primary disease 7%, Synchronous 15%, Metachronous 78%. Instrumentation: Carbon-fibre (85%), TiAl (11%), Non-Instrumented (3%). Separation Surgery (70%), En-bloc resection/Tomita surgery (30%); SABR/Proton Beam Planned: 70%. Average length of hospital stays 19.1 days; twenty patients required intensive care admission for an average 2.7 days. 30 Day Mortality 8.3% (n=2: COVID-19 during admission and ventriculitis post discharge), 1y Mortality – 16.7%, 3y Mortality – 25%; Synchronous Mortality 75% (n=3) at 3 years. 30 Day infection rate 3%; 1y infection rate 7%. 1 Non-instrumented case developed proximal junctional failure post proton beam therapy and required a vascularised fibular strut graft. 2-year Revision for Local Recurrence 5% (Revision at 23 months). Conclusion. There are very few case series of oligometastatic spinal disease due to the relatively new concept of adjuvant SABR and its limited availability. Solid tumours pre-dominated the histology in our series with metachronous disease being the most commonly operated disease state. 92% of cases were eligible for SABR. The majority (85%) of cases were performed with Carbon-fibre instrumentation and has been shown to be safe with no mechanical failures in this series. Infection rates are in keeping with patients requiring radical radiotherapy with 3% early and 7% late. 30-day mortality was 8.3%, 1y=16.7% and 25% at last follow up. Mortality, as expected, is highest within the synchronous disease group and should be operated on sparingly. With the current management strategy, there was no local recurrence at 1 year and excellent local recurrence rate at 2 years (5%). Although radical en bloc surgery carries significant morbidity, it should be considered in selective cases to achieve MLC. All Oligometastatic cases deserve extra consideration and specialist MDT as not all are suitable for SABR. Multimodal Hybrid therapy, incorporating less invasive surgical techniques and SABR, represents a paradigm shift in achieving MLC in oligometastatic spinal disease

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

In this study we aim to establish which symptoms and signs are able to reliably predict the presence or absence of cauda equina syndrome. Prospective collection of data was carried out over 10 months on all patients referred with suspected cauda equina syndrome(CES) to a single spinal unit. 28 patients were referred. MRI was normal in 4 (14%) patients. 4 (14%) had disc prolapse causing CES and 3 (11%) had spinal metastatic disease. All patients with CES presented with low back pain, unilateral sciatica, urinary dysfunction (painless retention 2, incontinence 2), altered perianal sensation and abnormal anal tone. 1 described constipation. Of patients without CES or malignancy 21 (100%) complained of low back pain, 19 (90%) sciatica (15 unilateral, 4 bilateral), 12 urinary dysfunction (incontinence 5, reduced sensation 3, painless retention 2, urgency 1, terminal dribbling 1) and 5 described altered bowel habit. 7 (33%) exhibited altered perianal sensation and 1 (5%) abnormal anal tone. The patients with spinal metastases all described back pain but no sciatica. 2 had urinary retention and constipation with 1 having abnormal perianal sensation and anal tone. This study suggests abnormal anal tone (sensitivity 1.0, specificity 0.95) and altered perianal sensation (sensitivity 1.0, specificity 0.67) are the most reliable predictors of CES. Thorough clinical examination is essential. Back pain with bladder and/or bowel dysfunction without sciatica should raise the suspicion of malignancy

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications. Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence. Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma

Study Design: A retrospective review of case notes and histology reports. Summary of Background Data: Up to 8% of cancer patients develop second malignancies. The vertebral column is frequently involved in metastatic disease and may represent the first manifestation of malignancy in up to 40% of patients. The rate of vertebral metastasis from a second tumour in patients with a known primary is not well known. Objective: We sought to identify the incidence of a second primary in patients referred to our unit with spinal malignancy and a previously diagnosed primary tumour. Subjects: 222 patients underwent definitive surgery for spinal metastatic disease of whom 135 had a prior history of malignancy. Outcome measures: Histological tissue of origin of spinal metastasis in light of previous known malignancy. Results: In 16 patients (11.9%) the vertebral histology differed from the initial primary. The period between first and second malignancies varied widely (19 months – 22 years). Thirteen patients (9.6%) had identifiable tissue origins for the metastasis that was not in keeping with the previous malignancy. Three further patients showed sufficient histological and imunohistochemical differences such that a further tumour of unknown origin and not de-differentiation of the previous tumour was suspected. Three previously unrecognised tumours were diagnosed on biopsy and eight on tissue obtained at definitive surgery. Conclusion: The incidence of second primaries, in particular myeloma, presenting with vertebral metastases is significant and should always be borne in mind when assessing patients and planning treatment. Biopsy should be performed when possible. Comparison needs to be made between the histological features of the previous primary and metastasis

Study Design: Descriptive case series. Objective: To report on the outcome of 4 patients treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to hypernephroma. Summary of background data: Patients with solitary spinal metastases from renal cell carcinoma (RCC) have better prognosis and show longer survival rates as compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radioresistant tumour, which can often present with both back pain and neurological deficit. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. 3 of the 4 had pre-operative embolization and all had radical resection of the primary tumour. Results: All patients reported significant pain relief and demonstrated neurological improvement. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. 3 were alive and well at 18, 26 and 39 months post-op with no radiological evidence of tumour recurrence. There were no major surgical complications. Conclusions: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Spinal metastatic disease can result in burst fracture and neurologic compromise. This study aims to examine the effects of tumour location, shape and surface texture on burst fracture risk in the metastatic spine using a parametric poroelastic finite element model. Tumours were found to be most hazardous in the posterior region of the vertebral body, whereas the multiple tumour scenarios reduced risk. Tumour shape may affect the mechanism of burst fracture. Serrated and smooth outer tumour surfaces yielded similar trends. These results can be used to improve guidelines for burst fracture risk assessment in patients with spinal metastases. This study aims to examine the effects of tumour location, shape and surface texture on burst fracture risk in the metastatic spine. Both tumour location and shape are important factors in assessing the risk of burst fracture in the meta-static spine. Improving risk prediction may reduce burst fracture in patients with spinal metastases. Vertebral bulge increased over 30% when the tumour was moved posteriorly. Conversely, for the multi-tumour scenarios, vertebral bulge and axial displacement decreased by 41% and 35% in comparison to a single central tumour. Anterior and lateral movement demonstrated only small effects. Vertebral bulge increased proportionally to mediolateral tumour length and axial displacement increased proportionally to superior-inferior tumour length. Similar trends were seen with smoothed and serrated tumour surfaces. Using a parametric poroelastic finite element model of a metastaticaly involved T7 spinal motion segment, fourteen single and two multi-tumour scenarios were analyzed, each comprising approximately 24% tumour volume. Ellispoidal tumours were positioned in central, anterior, posterior and lateral locations. Tumour shape was altered by adjusting tumour radii for a centrally located tumour. Tumours were modeled using smoothed and serrated outer surface configurations. Burst fracture risk was assessed by measuring maximum vertebral bulge and axial displacement under load. Tumours were found to be most hazardous in the posterior region of the vertebral body, whereas the multi-tumour scenarios reduced risk. Modeling of tumour surface texture did not impact shape or location effects. Tumour shape may affect the mechanism of burst fracture. Funding: This study was supported by the National Science and Engineering Research Council