Promoting postoperative recovery in patients with metastatic epidural spinal cord compression based on the concept of ERAS: a multicenter analysis of 304 patients.

BACKGROUND CONTEXT: Enhanced recovery after surgery (ERAS) has proven beneficial for patients undergoing orthopedic surgery. However, the application of ERAS in the context of metastatic epidural spinal cord compression (MESCC) remains undefined. PURPOSE: This study aims to establish a medical pathway rooted in the ERAS concept, with the ultimate goal of scrutinizing its efficacy in enhancing postoperative outcomes among patients suffering from MESCC. STUDY DESIGN/SETTING: An observational cohort study. PATIENT SAMPLE: A total of 304 patients with MESCC who underwent surgery were collected between January 2016 and January 2023 at two large tertiary hospitals. OUTCOME MEASURES: Surgery-related variables, patient quality of life, and pain outcomes. Surgery-related variables in the study included surgery time, surgery site, intraoperative blood loss, and complication. METHODS: From January 2020 onwards, ERAS therapies were implemented for MESCC patients in both institutions. Thus, the ERAS cohort included 138 patients with MESCC who underwent surgery from January 2020 to January 2023, whereas the traditional cohort consisted of 166 patients with MESCC who underwent surgery from January 2016 to December 2019. Clinical baseline characteristics, surgery-related features, and surgical outcomes were collected. Patient quality of life was evaluated using the Functional Assessment of Cancer Therapy-General Scale (FACT-G), and pain outcomes were assessed using the Visual Analogue Scale (VAS). RESULTS: Comparison of baseline characteristics revealed that the two cohorts were similar (all p>.050), indicating comparable distribution of clinical characteristics. In terms of surgical outcomes, patients in the ERAS cohort exhibited lower intraoperative blood loss (p<.001), shorter postoperative hospital stays (p<.001), lower perioperative complication rates (p=.020), as well as significantly shorter time to ambulation (P<0.001), resumption of regular diet (p<.001), removal of urinary catheter (p<.001), initiation of radiation therapy (p<.001), and initiation of systemic internal therapy (p<.001) compared with patients in the traditional cohort. Regarding pain outcomes and quality of life, patients undergoing the ERAS program demonstrated significantly lower VAS scores (p<.010) and higher scores for physical (p<.001), social (p<.001), emotional (p<.001), and functional (p<.001) well-being compared with patients in the traditional cohort. CONCLUSIONS: The ERAS program, renowned for its ability to expedite postoperative recuperation, emerges as a promising approach to ameliorate the recovery process in MESCC patients. Not only does it exhibit potential in enhancing pain management outcomes, but it also holds the promise of elevating the overall quality of life for these individuals. Future investigations should delve deeper into the intricate components of the ERAS program, aiming to unravel the precise mechanisms that underlie its remarkable impact on patient outcomes.

A New Treatment Strategy for Spinal Metastasis: The "Systemic Conditions, Effectiveness of Systemic Treatment, Neurology, and Oncology" Decision Framework System.

BACKGROUND AND OBJECTIVES: Treating metastatic spinal tumors poses a significant challenge because there are currently no universally applied guidelines for managing spinal metastases. This study aims to propose a new decision framework for the 12-point epidural spinal cord compression grading system to treat patients with metastatic spinal tumors and investigate its clinical effectiveness in a multicenter analysis. METHODS: This study analyzed 940 patients with metastatic spinal tumors between December 2017 and March 2023. The study provided the clinical evidence for the systemic conditions, effectiveness of systemic treatment, neurology, and oncology (SENO) decision framework among spine metastases. The SENO decision framework was launched in January 2021 in our hospitals, classifying patients into 2 groups: The non-SENO group (n = 489) consisted of patients treated between December 2017 and January 2021, while the SENO group (n = 451) comprised patients treated from January 2021 to March 2023. RESULTS: Patients in the SENO group were more likely to receive minimally invasive surgery (67.85% vs 58.69%) and less chance of receiving spinal cord circular decompression surgery (14.41% vs 24.74%) than patients in the non-SENO group ( P < .001). Furthermore, patients in the SENO group experienced fewer perioperative complications (9.09% vs 15.34%, P = .004), incurred lower hospitalization costs ( P < .001), had shorter length of hospitalization ( P < .001), and received systematic treatments for tumors earlier ( P < .001). As a result, patients in the SENO group (329.00 [95% CI: 292.06-365.94] days) demonstrated significantly improved survival outcomes compared with those in the non-SENO group (279.00 [95% CI: 256.91-301.09], days) ( P < .001). At 3 months postdischarge, patients in the SENO group reported greater improvements in their quality of life, encompassing physical, social, emotional, and functional well-being, when compared with patients in the non-SENO group. CONCLUSION: The SENO decision framework is a promising approach for treating patients with metastatic spinal tumors.

A Web-Based Calculator to Predict Early Death Among Patients With Bone Metastasis Using Machine Learning Techniques: Development and Validation Study.

BACKGROUND: Patients with bone metastasis often experience a significantly limited survival time, and a life expectancy of <3 months is generally regarded as a contraindication for extensive invasive surgeries. In this context, the accurate prediction of survival becomes very important since it serves as a crucial guide in making clinical decisions. OBJECTIVE: This study aimed to develop a machine learning-based web calculator that can provide an accurate assessment of the likelihood of early death among patients with bone metastasis. METHODS: This study analyzed a large cohort of 118,227 patients diagnosed with bone metastasis between 2010 and 2019 using the data obtained from a national cancer database. The entire cohort of patients was randomly split 9:1 into a training group (n=106,492) and a validation group (n=11,735). Six approaches-logistic regression, extreme gradient boosting machine, decision tree, random forest, neural network, and gradient boosting machine-were implemented in this study. The performance of these approaches was evaluated using 11 measures, and each approach was ranked based on its performance in each measure. Patients (n=332) from a teaching hospital were used as the external validation group, and external validation was performed using the optimal model. RESULTS: In the entire cohort, a substantial proportion of patients (43,305/118,227, 36.63%) experienced early death. Among the different approaches evaluated, the gradient boosting machine exhibited the highest score of prediction performance (54 points), followed by the neural network (52 points) and extreme gradient boosting machine (50 points). The gradient boosting machine demonstrated a favorable discrimination ability, with an area under the curve of 0.858 (95% CI 0.851-0.865). In addition, the calibration slope was 1.02, and the intercept-in-large value was -0.02, indicating good calibration of the model. Patients were divided into 2 risk groups using a threshold of 37% based on the gradient boosting machine. Patients in the high-risk group (3105/4315, 71.96%) were found to be 4.5 times more likely to experience early death compared with those in the low-risk group (1159/7420, 15.62%). External validation of the model demonstrated a high area under the curve of 0.847 (95% CI 0.798-0.895), indicating its robust performance. The model developed by the gradient boosting machine has been deployed on the internet as a calculator. CONCLUSIONS: This study develops a machine learning-based calculator to assess the probability of early death among patients with bone metastasis. The calculator has the potential to guide clinical decision-making and improve the care of patients with bone metastasis by identifying those at a higher risk of early death.

Prediction of postoperative health-related quality of life among patients with metastatic spinal cord compression secondary to lung cancer.

Background: Health-related quality of life (HRQoL) is a critical aspect of overall well-being for patients with lung cancer, particularly those with metastatic spinal cord compression (MSCC). However, there is currently a lack of universal evaluation of HRQoL in this specific patient population. The aim of this study was to develop a nomogram that can accurately predict HRQoL outcomes in patients with lung cancer-related MSCC. Methods: A total of 119 patients diagnosed with MSCC secondary to lung cancer were prospectively collected for analysis in the study. The least absolute shrinkage and selection operator (LASSO) regression analysis, along with 10-fold cross-validation, was employed to select the most significant variables for inclusion in the nomogram. Discriminative and calibration abilities were assessed using the concordance index (C-index), discrimination slope, calibration plots, and goodness-of-fit tests. Net reclassification index (NRI) and integrated discrimination improvement (IDI) analyses were conducted to compare the nomogram's performance with and without the consideration of comorbidities. Results: Four variables were selected to construct the final nomogram, including the Eastern Cooperative Oncology Group (ECOG) score, targeted therapy, anxiety scale, and number of comorbidities. The C-index was 0.87, with a discrimination slope of 0.47, indicating a favorable discriminative ability. Calibration plots and goodness-of-fit tests revealed a high level of consistency between the predicted and observed probabilities of poor HRQoL. The NRI (0.404, 95% CI: 0.074-0.734, p = 0.016) and the IDI (0.035, 95% CI: 0.004-0.066, p = 0.027) confirmed the superior performance of the nomogram with the consideration of comorbidities. Conclusions: This study develops a prediction nomogram that can assist clinicians in evaluating postoperative HRQoL in patients with lung cancer-related MSCC. This nomogram provides a valuable tool for risk stratification and personalized treatment planning in this specific patient population.

Development of a novel 12-point grading system for evaluating epidural spinal cord compression and its clinical implications.

BACKGROUND CONTEXT: The assessment of epidural spinal cord compression (ESCC) plays a crucial role in clinical decision-making, yet the current grading system lacks reliability and requires improvements. PURPOSE: The study aims to develop a reliable grading system for evaluating ESCC and to investigate its association with the neurological status of patients. STUDY DESIGN/SETTING: A prospective cohort study. PATIENT SAMPLE: A total of 330 patients with metastatic spinal disease were included in the study. OUTCOME MEASURES: The main outcome was the neurological status evaluated using the American Spinal Injury Association (ASIA) scale. METHODS: We proposed a novel grading system, called the 12-point ESCC grading system, to evaluate ESCC based on findings from spinal magnetic resonance imaging (MRI). This new grading system consists of 12 grades, ranging from Grade 0 to 3, with higher grades indicating more severe ESCC. The detailed information about the sagittal image of the spine and the severity of spinal cord swelling was considered in this new grading system. The Spearman correlation analysis and logistic regression analysis were employed to investigate the correlation between the previous 6-point grading system and ASIA, as well as between the new 12-point ESCC grading system and ASIA. The prediction effectiveness was evaluated using the area under curve (AUC) analysis. RESULTS: Patients with higher grades in the 12-point ESCC grading system exhibited a higher likelihood of experiencing a worse neurological condition. Specifically, patients with grades 2a to 2d and 3a to 3d according to the new 12-point ESCC grading system were significantly associated with more complete paralysis (p<.001) compared with patients with grade 0. The Spearman correlation coefficient was 0.729 between the previous 6-point ESCC grading system and ASIS and 0.750 between the new 12-point ESCC grading system and ASIS. When categorizing ASIS into complete paralysis and other neurological statuses, the 6-point ESCC score yielded an AUC of 0.820, which increased to 0.860 with the new 12-point ESCC grading system. Furthermore, when ASIS was divided into normal and abnormal neurological statuses, the AUC increased from 0.889 to 0.906. Additionally, spinal cord swelling was significantly associated with more complete paralysis (p<.001) and abnormal neurological status (p<.001) based on the new 12-point ESCC grading system. CONCLUSIONS: The new 12-point ESCC grading system provides more detailed information and further improves the prediction effectiveness for evaluating neurological status compared with the previous 6-point ESCC grading system. In the new 12-point ESCC grading system, higher grades or the presence of spinal cord swelling are indicative of a worse neurological condition.

Machine learning-based algorithms to predict severe psychological distress among cancer patients with spinal metastatic disease.

BACKGROUND CONTEXT: Metastatic spinal disease is an advanced stage of cancer patients and often suffer from terrible psychological health status; however, the ability to estimate the risk probability of this adverse outcome using current available data is very limited. PURPOSE: The goal of this study was to propose a precise model based on machine learning techniques to predict psychological status among cancer patients with spinal metastatic disease. STUDY DESIGN/SETTING: A prospective cohort study. PATIENT SAMPLE: A total of 1043 cancer patients with spinal metastatic disease were included. OUTCOME MEASURES: The main outcome was severe psychological distress. METHODS: The total of patients was randomly divided into a training dataset and a testing dataset on a ratio of 9:1. Patients' demographics, lifestyle choices, cancer-related features, clinical manifestations, and treatments were collected as potential model predictors in the study. Five machine learning algorithms, including XGBoosting machine, random forest, gradient boosting machine, support vector machine, and ensemble prediction model, as well as a logistic regression model were employed to train and optimize models in the training set, and their predictive performance was assessed in the testing set. RESULTS: Up to 21.48% of all patients who were recruited had severe psychological distress. Elderly patients (p<0.001), female (p =0.045), current smoking (p=0.002) or drinking (p=0.003), a lower level of education (p<0.001), a stronger spiritual desire (p<0.001), visceral metastasis (p=0.005), and a higher Eastern Cooperative Oncology Group (ECOG) score (p<0.001) were significantly associated with worse psychological health. With an area under the curve (AUC) of 0.865 (95% CI: 0.788-0.941) and an accuracy of up to 0.843, the gradient boosting machine algorithm performed best in the prediction of the outcome, followed by the XGBooting machine algorithm (AUC: 0.851, 95% CI: 0.768-0.934; Accuracy: 0.826) and ensemble prediction (AUC: 0.851, 95% CI: 0.770-0.932; Accuracy: 0.809) in the testing set. In contrast, the AUC of the logistic regression model was only 0.836 (95% CI: 0.756-0.916; Accuracy: 0.783). CONCLUSIONS: Machine learning models have greater predictive power and can offer useful tools to identify individuals with spinal metastatic disease who are experiencing severe psychological distress.

Treatment of patients with metastatic epidural spinal cord compression using an enhanced recovery after surgery program.

Purpose: The aims of this study were to introduce a new medical, pathway based on the concept of "enhanced recovery after surgery" (ERAS) for patients with metastatic epidural spinal cord compression (MESCC), and to test whether the ERAS program could improve clinical metrics among such patients. Methods: Data from patients with MESCC (n = 98), collected between December 2016 and December 2019 (Non-ERAS cohort), and from 86 patients with metastatic epidural spinal cord compression collected between January 2020 and December 2022 (ERAS cohort), were retrospectively analyzed. Patients were treated by decompressive surgery combined with transpedicular screw implantation and internal fixation. Patient baseline clinical characteristics were collected and compared between the two cohorts. Surgical outcomes analyzed included operation time; intraoperative blood loss; postoperative length of hospital stay; time to ambulation, regular diet, urinary catheter removal, and radiation therapy; perioperative complications; anxiety; depression; and satisfaction with treatment. Results: No significant differences in clinical characteristics were found between the non-ERAS and enhanced recovery after surgery cohorts (all p > 0.050), indicating that the two cohorts were comparable. Regarding surgical outcomes, the enhanced recovery after surgery cohort had significantly less intraoperative blood loss (p < 0.001); shorter length of postoperative hospital stay (p < 0.001); shorter time to ambulation (p < 0.001), regular diet (p < 0.001), urinary catheter removal (p < 0.001), radiation administration (p < 0.001), and systemic internal therapy (p < 0.001); lower perioperative complication rate (p = 0.024); less postoperative anxiety (p = 0.041); and higher score for satisfaction with treatment (p < 0.001); whereas operation time (p = 0.524) and postoperative depression (p = 0.415) were similar between the two cohorts. Compliance analysis demonstrated that ERAS interventions were successfully conducted in the vast majority of patients. Conclusion: The enhanced recovery after surgery intervention is beneficial to patients with metastatic epidural spinal cord compression, according to data on intraoperative blood loss; length of hospital stay; time to ambulation, regular diet, urinary catheter removal, radiation exposure, and systemic internal therapy; perioperative complication; alleviation of anxiety; and improvement of satisfaction. However, clinical trials to investigate the effect of enhanced recovery after surgery are needed in the future.

Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis.

Purpose: The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC). Methods: A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient's baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization. Results: Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss. Conclusions: Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.

Percutaneous cementoplasty for painful osteolytic distal femur metastases: a case report.

Percutaneous cementoplasty has been shown to immediately restore the mechanical stability of affected bones, prevent further risk of bone fractures, and allow immediate weight bearing. It is emerging as one of the most promising procedures for patients with painful bone metastasis who are unsuitable for surgery or who show resistance to radiotherapy and/or analgesic therapies. This study aimed at describing the procedure, indications, and benefits of percutaneous cementoplasty for painful osteolytic distal femur metastases. We report the case of a painful metastatic lesion in the left distal femur secondary to non-small-cell lung cancer in a 58-year-old woman. The patient underwent percutaneous cementoplasty and experienced effective pain relief and recovery of knee function postoperatively. In addition, no perioperative complication was observed. Percutaneous cementoplasty for osteolytic distal femur metastases offers effective pain relief and restores impaired knee function. Although this method may be a safe option, larger samples of retrospective or prospective confirmation are warranted.

Tantalum rod implantation for femoral head osteonecrosis: survivorship analysis and determination of prognostic factors for total hip arthroplasty.

PURPOSE: The purpose of this study was to evaluate the moderate survival data of porous tantalum rod implants for the treatment of osteonecrosis of the femoral head (ONFH). Additionally, some independent prognostic factors for conversion to total hip arthroplasty (THA) were identified. METHODS: The porous tantalum rod population was obtained from a prospective, consecutive group of patients treated for Steinberg stage I and II osteonecrosis from April 2009 through July 2011. The historical core decompression and impaction of bone filling particle subjects underwent surgery from April 2007 through March 2009. Surgical data including time of surgery, blood loss, and cell transfusions were recorded. Post-operative values were measured for hospitalization length as well as days requiring a patient-controlled analgesia (PCA) pump. Primary outcomes were Harris hip score and survivorship analysis. Demographics and baseline characteristics included age, sex, etiology, bilateral disease, associated chronic systemic disease, Steinberg stage, Harris hip score, accompanied with bone marrow edema of femoral head, and osteonecrotic lesion size. RESULTS: Demographic/baseline characteristics were similar between two groups. At the post-operative follow-up of 62 months, Harris hip scores were significantly increased (P < 0.0001) when compared to that before surgery in both groups. The magnitude of increase in the tantalum rod implant group was significantly greater than that in the control group (P = 0.0426). With an average follow-up of 48 months (range, 38-62 months), the tantalum rod group had an 84.6 % survival rate. With an average follow-up of 72 months (range, 67-85 months), the control group had a 63.3 % survival rate. A comparison of Kaplan-Meier curves showed significantly higher cumulative survival rates (P = 0.048) for hips with implantation of the porous tantalum rod (74.1 % at 62 months) than for those with impaction composite bone material (49.9 % at 62 months). The Cox proportional-hazard model revealed that implantation of tantalum rod (P = 0.012), bone marrow edema (P = 0.003), corticosteroids intake (P = 0.007), and age less than 50 years (P = 0.014) were the independent prognostic factors related to conversion into THA. CONCLUSIONS: Compared with the traditional impaction composite bone material technique, implantation of tantalum rod in the treatment of Steinberg stages I and II ONFH can obtain better clinical results and higher cumulative survival rates. For patients without the use of corticosteroids, and especially for hips without bone marrow oedema, the clinical results from our study show highly encouraging survival rates and a delay in or prevention of conversion into THA.

[A modified porous tantalum implant technology for osteonecrosis of the femoral head: survival and prognostic evaluations of conversion into total hip arthroplasty].

OBJECTIVE: To assess the survival and prognostic significance of various demographic and radiographic parameters for conversion into total hip arthroplasty after treatment with a modified porous tantalum implant technology for early and intermediate stages of osteonecrosis of the femoral head (ONFH). METHODS: This study included 45 patients (59 hips) with Steinberg Stage I-IV A ONFH undergoing progressively core decompression, impaction bone grafting of 5 mm-composite bone filling material and inserting of a porous tantalum implant. Weight-bearing was forbidden within the first 3 months after implants. RESULTS: A total of 57 hips (44 patients) were available during a mean follow-up period of 44.8 (11-62) months. Their mean age was 43 (21-70) years. The mean Harris hip score significantly improved from 59.93 ± 2.80 preoperative to 77.84 ± 2.95 at the last follow-up (P < 0.001). Overall, 11 hips (19.30%) were converted into total hip arthroplasty. The overall survival rate was 72.49% at 60 months postoperatively. The Cox proportional hazard model revealed that bone marrow edema was an independent prognostic factor related with a conversion into total hip arthroplasty. CONCLUSION: Higher survival rates may be obtained from modified tantalum implant technology for early and intermediate stages of ONFH. And prognosis was poor for patients of ONFH with bone marrow edema.

[Relationship of motor deficits and imaging features in metastatic epidural spinal cord compression].

OBJECTIVE: To explore the relationship of motor deficits of the lower extremities with the imaging features of malignant spinal cord compression (MESCCs). METHODS: From July 2006 through December 2008, 56 successive MESCC patients were treated at our department. All were evaluated by magnetic resonance imaging and computed tomography and were scored according to motor deficits Frankel grading on admission. Imaging assessment factors of main involved vertebrae were level of vertebral metastatic location, epidural space involvement, vertebral body involvement, lamina involvement, posterior protrusion of posterior wall, pedicle involvement, continuity of main involved vertebrae, fracture of anterior column, fracture of posterior wall, location in upper thoracic spine and/or cervicothoracic junction. RESULTS: Occurrence was the same between paralytic state of MESCCs and epidural space involvement of imaging features. Multiple regression equation showed that paralytic state had a linear regression relationship with imaging factors of lamina involvement (X1), posterior protrusion of posterior wall (X2), location in upper thoracic spine and/or cervicothoracic junction (X7) of main involved vertebrae. The optimal regression equation of paralytic state (Y) and imaging feature (X) was Y = -0.009 +0.639X, + 0.149X, +0.282X. Lamina involvement of main involved vertebrae has a greatest influence upon paralytic state of MESCC patients. CONCLUSIONS: Imaging factors of lamina involvement, posterior protrusion of posterior wall, location in upper thoracic spine and/or cervicothoracic junction of main involved vertebrae can predict the paralytic state of MESCC patients. MESCC with lamina involvement is more easily encroached on epidural space.