Non-operative management of spinal metastases: A prognostic model for failure
Introduction
Due to advancements in surveillance and medical treatments for cancer, there are now more patients living with spinal metastases than ever before in history [1,2]. Current estimates suggest that over 20,000 new diagnoses of metastatic epidural compression are made each year [1,3]. The development of spinal metastases may portend increased risk for physiologic decline, neurological deterioration and mortality within the year of diagnosis [1,[3], [4], [5], [6]].
While numerous investigations have shown benefit for both operative and non-surgical management of spinal metastases in select situations [[1], [2], [3], [4], [5],[7], [8], [9], [10], [11], [12], [13], [14]], several suggest a surgical approach may be more advantageous in terms of preserving ambulatory function [2,4,7,11,14]. Surgery for spinal metastases is known to be associated with high rates of peri-operative morbidity as well as the potential for iatrogenic neurologic decline [5,6,8,9,[11], [12], [13]]. Many patients will elect non-operative treatment in order to avoid peri-operative complications [1]. However, non-operative treatment may fail and patients who receive surgery following non-operative management have been reported to be at increased risk of wound breakdown, infection, and construct failure [3,7]. Therefore, it would be useful to identify patients who are at increased risk of failure of non-operative management at the time of presentation.
In this context, we sought to evaluate factors at presentation that were associated with the eventual need for surgery after non-operative treatment had been initiated. We performed this investigation using the medical records of patients treated at Brigham and Women’s Hospital and Massachusetts General Hospital over the course of 2005–2017.
Section snippets
Data source
We conducted this retrospective study using medical information contained in the Partner’s Healthcare Data Repository (RPDR) and the electronic medical records of two tertiary academic centers. Data from these centers have been successfully utilized in the past to study the treatment of primary bone tumors, metastatic disease and outcomes following operative and non-surgical management of spinal metastases [6,[15], [16], [17]]. We included patients 40–80 years old in this investigation if they
Results
We identified 1205 patients meeting eligibility criteria. Among these individuals, 371 received surgery as part of the primary intervention, leaving 834 patients who were initially treated with a non-operative approach to be included in this analysis. We found that 77 individuals (9%; 95% CI 7%, 11%) who initially received non-operative management underwent a surgical intervention within one year of presentation, meeting our definition of non-operative failure (Fig. 1).
Within the entire cohort
Discussion
The treatment of patients with spinal metastases is complex and frequently requires a multi-disciplinary approach [1,[8], [9], [10]]. At the time of initial presentation, decision making regarding treatment is often informed by the anticipated length of patient survival, tumor characteristics, as well as structural instability and symptoms [1,2,[4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14],21]. In the wake of improvements in peri-operative medical management, the utilization of
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
Funding
This research was funded by a National Institutes of Health (NIH-NIAMS) grant (K23-AR071464) to Dr. Schoenfeld (P30-AR072577) to Dr. Katz and (K24-AR057827) to Dr. Losina. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the NIH or the Federal government.
Acknowledgements
This research was funded by a National Institutes of Health (NIH-NIAMS) grant (K23-AR071464) to Dr. Schoenfeld. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the NIH or the Federal government.
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