Spinal Instability Neoplastic Score
Spinal Instability Neoplastic Score
From the *Combined Neurosurgery and Orthopaedic Spine Program, Department of Orthopaedics, University of British Columbia, Vancouver, BC;
Iowa Spine and Brain Institute, Waterloo, IA; Neurosurgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Neurological Surgery, University of Virginia Medical Center, Charlottesville, VA;
Department of Orthopaedics, University of California, San Francisco, CA;
!Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA;**Toronto Western Hospital Spinal Program, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Orthopaedics and Traumatology, Ospedale Maggiore, Ausl Bologna, Bologna,
Italy; Department of Neurological Surgery, University of California, San
Francisco, CA; Huntsman Cancer Institute and Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT;
Department of Orthopedics, University of Minnesota, Minneapolis, MN;
!!Department of Orthopedic Oncology, Regina Elena Institute, Rome, Italy;
***Department of Orthopaedics, Mayo Clinic, Rochester, MN; Department of Neurosurgery, Northwestern University, Chicago, IL; Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh,
PA; Department of Neurosurgery, Johns Hopkins University, Baltimore,
MD; Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA; !!!Department of Radiation Oncology, MA General Hospital, Boston, MA; ****Department of Neurological Surgery, The Ohio State
University, Columbus, OH; Department of Oncology & Orthopedic
Oncology, Mayo Clinic, Rochester, MN; Departments of Medical Oncology and Neurosurgery, MD Anderson Cancer Center, University of
Texas, Houston, TX; Department of Neurological Surgery, Mount Sinai
Hospital, New York, NY; !!!!Department of Orthopaedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan;
*****National Center for Spinal Disorders, Budapest, Hungary; Catholic University of Parana, Curitiba-Pr, Brazil; H Lee Moffitt Cancer
Center and Research Institute and Departments of Neurosurgery and Interdisciplinary Oncology, University of South Florida College of Medicine,
Tampa, FL; Department of Radiation Oncology, Memorial SloanKettering Cancer Center, New York, NY; and Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, SK,
Canada.
Acknowledgment date: August 12, 2009. First revision date: October
29, 2009. Second revision date: December 3, 2009. Acceptance date:
April 2, 2010.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
Corporate/Industry funds were received in support of this work. No
benefits in any form have been or will be received from a commercial
party related directly or indirectly to the subject of this manuscript.
Address correspondence and reprint requests to Charles G. Fisher,
MD, MHSc, Deparement of Orthopaedics, University of British Columbia, Blusson Spinal Cord Centre, 818 W. 10th Avenue, 6th floor,
Vancouver, BC, Canada V5Z 1M9; E-mail: [email protected]
E1221
Metastatic disease of the spine remains a common problem and its incidence is increasing as detection methods
improve and treatments for primary cancers allows patients with active disease to have a longer life expectancy.1
Recent data has shown that patients with metastatic epidural cord compression who undergo surgical decompression and reconstruction followed by radiation have
superior outcomes to those who undergo radiation alone
in terms of preservation of neurologic function and pain
relief.2 There is further evidence that surgical decompression for spinal cord compression from metastatic disease
before radiation therapy results in improved neurologic
outcomes and fewer wound complications.2,3 Thus, it
appears critical to develop treatment plans for patients
with spinal metastasis via a multidisciplinary approach
between medical oncologists, radiation oncologists, and
spine surgeons so that proper treatment and timing of
treatment can be employed.
For patients with spinal metastasis or primary neoplastic disease, neurologic status is only one factor that
influences surgical decision-making. While all patients
with the diagnosis of a primary spine tumor should receive surgical consultation, it is still not completely established as to when patients with metastatic disease of
the spine should receive surgical consultation and intervention. Surgical treatment decisions are broadly based
on spinal stability and patient-specific factors that include patient health, prognosis,4 and tumor histology.
Because spinal instability is not well defined in the literature, there are no evidence-based guidelines currently
available to aid in assessment of a particular patients
risk for spinal instability in the setting of neoplastic spinal disease. The concept of spinal instability, however,
remains critical in the surgical decision-making process.
Spinal instability as the result of a neoplastic process
differs significantly from high-energy traumatic injuries
in the pattern of bony and ligamentous involvement, potential for healing, neurologic manifestations, and bone
quality, and therefore requires a specific and different set
of criteria for stability assessment. Recently, systematic
reviews of the cervical and thoracolumbar spine literature have been unable to definitively describe what constitutes neoplastic spinal instability.5,6 Thus, for the purposes of clinical decision-making and future research, the
Spine Oncology Study Group (SOSG) defines spine instability as loss of spinal integrity as a result of a neoplastic process that is associated with movement-related
pain, symptomatic or progressive deformity, and/or neural compromise under physiologic loads.
Because of the lack of guidelines, spine surgeons currently rely on clinical experience to determine whether
instability is present in the setting of spinal neoplasia and
surgery is indicated. Although demanding for the spine
surgeon, the diagnosis of instability for the nonsurgeon
may be extremely challenging, often leading to inappropriate referrals of patients without instability or undertreatment of patients with instability, risking pain,
and/or neurologic deterioration. Development of a sim-
Expert Opinion
The SOSG is an international group of 30 spine oncology experts and thought leaders from North America, Europe, South
America, and Asia who meet biannually to discuss research,
assess the best evidence for current practices, and formulate
clinical trials to advance the field of spine oncology. Guyatt et
al8 have highlighted that a key component to evidence-based
medicine (especially when higher levels of evidence fall short) is
to employ consensus expert opinion.
Delphi Technique
The Delphi method is typically a group communication among
a panel of geographically dispersed experts. The technique allows the group to deal systematically with a complex problem
or task (in this case the question of how to define neoplastic
spinal instability).8 10 A modified Delphi process was used to
collect and distill knowledge from the SOSG by means of a
series of questionnaires interspersed with controlled opinion
feedback for the production of suitable information for decision-making.10
The modified process involved 7 defined steps for review of
the opinions.
1. An initial meeting of the SOSG was undertaken that included a round-table discussion, moderated by an appointed chairperson. The criteria deemed important to
clinical decision-making were identified. Twenty-four orthopedic and neurosurgical spine surgeons and oncologists with expertise in the area of spinal oncology were
asked to list factors relevant to the definition of spinal
instability in the oncology setting. The first round of criteria was then further organized, and the terminology
Table 1. Results of the Statistical Analysis of Round 1 and 2 of the Content Validity Surveys
Factors Associated With Instability
Presence of pain at rest
Character of pain (i.e., changes with mobility)
Sclerotic tumor
Pain with percussion
Subluxation/translation
Occipitocervical location
Cervicothoracic junction location
Complete pedicle involvement (bilateral)
Progression of deformity
Midcervical location
Unilateral pedicle involvement
Left Skewness
X
X
X
Right Skewness
X
X (pointed)
X (pointed)
X
X (pointed)
X (pointed)
X
ECOG/Karnofsky Performance Status assigns relative weight to the responses based on the pattern of their distribution. Left skewness indicates a pile-up of
scores to the left of, or below, the mean; right skewness is a pile-up of scores to the right of, or above, the mean. Strong skewness shows a significantly pointed
distribution. T-test comparisons of Round 1 and 2 responses were made to determine whether subsequent panel discussion swayed opinions on contributing
factors.
2.
3.
4.
5.
6.
7.
Statistical Analysis
Descriptive statistics for the rankings for the 40 factors associated with spinal instability were performed, including skewness
and kurtosis measures. Skewness and kurtosis are measures
indicating a departure from a normal distribution. Paired t tests
were used to assess the differences between the ratings by physician at Round 1 and Round 2 for the instability factors.
Results
Twenty-four fellowship trained spine surgeons (of the 26
in the group) completed the original questionnaire. His-
tograms were developed to assess the distribution of answers, and the skewness (a pileup of scores to the left or
right of the mean) and kurtosis (pointedness or flatness of the distribution) were assessed, and significant departures from the normal distribution were noted (Table 1).
All 24 physicians ranked the resulting 40 factors. Nine
factors scored greater than 70 and 19 scored between 40
and 70. The highest ranked factors included subluxation/translation (86.67 # 11.95), progression of deformity (86.52 # 13.60), facet destruction bilaterally
(78.75 # 13.85), and character of neurologic changes
(with motion) (77.71 # 19.89). The anatomic areas of
most concern were the occipitocervical junction
(70.83 # 16.33) and the cervicothoracic junction
(72.29 # 21.01).
Twenty surgeons subsequently completed the Round
2 questionnaire, and their answers were compared with
those provided in Round 1 (but only for those 20 surgeons) to determine whether there were any significant
changes of opinion that could be attributed to the group
discussion. Responses were compared via paired t tests.
The factors for which there was significant change at the
P " 0.05 level are listed in Table 1.
After integrating information from the previous
SOSG discussions and the 2 rounds of questionnaires, a
preliminary scoring system was developed. Consolidation of the scoring system was accomplished after final
Score
3
2
1
0
Score
2
1
0
Subluxation/translation present
De novo deformity (kyphosis/scoliosis)
Normal alignment
Score
4
2
0
This category is meant to describe spinal alignment between motion segments that are affected by tumor. Scoring of de novo deformity such as
kyphosis and/or scoliosis requires knowledge of prior imaging or may be
assessed with upright compared with supine radiographs.
Score
3
2
1
0
Presence and extent of vertebral body height collapse are used to assign a
contribution of the score to the anterior and middle columns.
Score
3
1
0
pathologic fracture of T10 (Figure 1). She had mechanical back pain that was relieved by lying down. She
was neurologically intact on examination. Supine to
upright radiographs demonstrated an increase in kyphosis of 20.
SINS scoring for this patient was scored as follows:
spine locationsemirigid spine (T10) $ 1; mechanical
painpresence of mechanical pain $ 3; bone lesion
qualitylytic $ 2; radiographic spinal alignment
kyphosis $ 2; vertebral body collapse!50% $ 3; posterolateral involvement of spinal elements bilateral $
3. The final tally of component scores yielded 14 out of a
possible 18. This condition is deemed as indeterminate
instability but falls within the range of lesions that warrant surgical consultation for the oncologist and should
be considered a possible surgical candidate depending on
prognosis and other patient factors.
Case 2. A 65-year-old man with a 70-pack/yr history of
smoking presents with severe upper cervical neck pain
that was exacerbated by head rotation and relieved
slightly by supine posture. He had greater occipital
Figure 2. A, Sagittal computed tomography (CT) scan demonstrating lytic lesion of the left C2 lateral mass with pathologic fracture
and C1C2 subluxation. B, Coronal CT scan demonstrates extent of
lytic lesion and subluxation of left C1C2 articulation through the
pathologic fracture.
Figure 3. A, Axial CT scan demonstrating lytic lesion of T10 involving severe destruction of the
right pedicle. B, Multiple sequential sagittal magnetic resonance
images of the metastatic renal
cell lesion in T10.
system has been validated and proven to comprehensively address all or even most of the important factors
involved in metastatic spine instability.
Previous studies in the spinal oncology literature have
used instability criteria adopted from trauma situations
or have failed to define the term instability entirely. In
studies that do assign a predetermined definition of instability, the criteria are often derived from biomechanical studies13 or adapted from theoretical considerations
without having been subject to rigorous methodologic
process or validation.14,15 Other authors have used clinical and symptom-related criteria to define instability in
their series of surgical treatment for metastatic spine disease.16 19 The NOMS (neurologic, oncologic, mechanical instability, systemic disease) criteria for decision-making have been used to guide clinicians in
choosing between radiation and surgical treatment for
metastatic spine tumors.16 20 The mechanical instability component of the criteria relies solely on the assessment of a patients movement-related pain. Different
types of motions and postures are characteristic of mechanical pain (and thus, as defined by NOMS, instability).16 20 This classification system has not been validated and fails to consider other key components of
instability such as radiographic parameters. In 2 recent
systematic reviews of instability in the setting of neoplastic disease of the cervical and thoracolumbar spine, it
was shown that there is a lack of level I evidence and
scarce level II evidence to clearly define the issue.5,6 Nevertheless, several clinical and radiographic parameters
were identified that likely relate to spinal instability with
neoplastic disease.
Mechanical (activity-related) pain is a consistent feature of oncologic instability.16 20 Axial spinal pain,
which is a mechanical pain exacerbated by movement
and relieved by recumbence, has been considered to be
associated with a structural abnormality in the spinal
column.16 22 Some authors report that a majority of patients presenting with spine metastases have mechanical
neck or back pain.20,23 Other types of pain, such as that
associated with periosteal stretching or nerve root/spinal
cord compression, are not indicative of instability, although they may coexist with instability. These types of
pain are clinically distinguishable by their distribution,
severity, and quality and are influenced by factors that
increase venous pressure (such as recumbency) or decrease edema (such as steroids). As described earlier, mechanical back or neck pain has been used as a component
of the NOMS classification system to aid in guiding
treatment for metastatic spinal disease.16 20 However,
pain is not the only feature that may be important in
defining spinal instability in the setting of neoplastic
disease.
Tumor size24 and location also influence the stability
of the spine. Involvement of more than 50% of the vertebral body could represent instability, as tumor size and
cross-sectional area within the vertebral body have been
shown to predict risk of pathologic fracture.13,2528 The
Score
3
2
1
0
3
1
0
2
1
0
4
2
0
3
2
1
0
3
1
0
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