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Table of Contents    
Year : 2023  |  Volume : 71  |  Issue : 5  |  Page : 872-874

Unstable Vertebral Spine Metastasis – Does the Time to Refer Matter?

1 Department of Neurosurgery, AIIMS, Bhubaneswar, Odisha, India
2 Department of Neurosurgery, AIIMS, Delhi, India

Date of Web Publication18-Oct-2023

Correspondence Address:
P Sarat Chandra
Room 706, 6th Floor, CN Centre, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.388119

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How to cite this article:
Dash C, Chandra P S. Unstable Vertebral Spine Metastasis – Does the Time to Refer Matter?. Neurol India 2023;71:872-4

How to cite this URL:
Dash C, Chandra P S. Unstable Vertebral Spine Metastasis – Does the Time to Refer Matter?. Neurol India [serial online] 2023 [cited 2023 Dec 7];71:872-4. Available from:

Vertebral metastasis (VM) is common in patients with cancer and requires a multidisciplinary team for the proper management of such patients. Delayed diagnosis and treatment of such tumors may lead to uncontrolled growth with spinal instability, which may be associated with neural compression. However, early diagnosis of VM is a challenge[1] as such patients often present with nonspecific symptoms like backache, which is common in the middle-aged population. Hence, symptomatic spinal cord compression occurs in approximately 25%–50% of patients with spinal metastasis.[2] Multiple myeloma is the most common bone metastasis, followed by malignancies of the breast, lung, prostate, kidney, thyroid, and gastrointestinal tract.[3] Surgical decompression in the case of neural compression is well established in the literature.[4] The landmark study by Patchell et al.[5] proved that direct decompression surgery plus radiotherapy was superior to radiotherapy alone in case of spinal compression by metastatic disease. In the case of metastatic spinal cord compression, patients in whom surgery is done within 48 h of the onset of symptoms tend to have better neurologic outcomes compared to those operated on after 48 h of the onset of symptoms.[6] The thoracic spine and the lumbar spine are the two most common areas of metastasis in the spinal column.[7] Various predictors of instability following spinal metastases in the thoracolumbar spine include the magnitude of spinal loading, bone density, tumor location within the vertebrae and spine, and the tumor type.[7] The Spinal Instability Neoplastic Score (SINS) score introduced by the Spinal Oncology Group in 2010 has helped in the standardization of the diagnosis of spinal instability in patients with VM.[8] SINS is known to have a significant correlation with patient-reported outcomes at baseline and change in patient-reported outcomes posttreatment.[8] Versteeg et al.[9] analyzed patients with spinal metastases who were treated with palliative surgery or radiotherapy and found that the SINS score was significantly higher in patients requiring surgery and it decreased significantly among patients in both groups, once the SINS scoring system was incorporated into the clinical practice. Patients with mechanical instability as per the SINS criteria tend to have better outcomes and pain relief with surgery[10] plus radiotherapy compared to radiotherapy alone.

The neurologic, oncologic, mechanical, and systemic (NOMS) decision framework integrates multimodality therapy to optimize local tumor control, pain relief, and restoration or preservation of neurologic function and helps in minimizing morbidity in these subsets of patients who are generally systemically ill.[11] Patients who are operated on in emergency hours with unstable spine are likely to face problems with proper planning, getting trained manpower, and arrangement of preferred surgical implants, and such circumstances may lead to adverse outcomes in patients.[12] Patients who receive timely surgery and are not operated during emergency hours with acute neurologic deficits incur less cost compared to those patients who require urgent surgical intervention.[13] Patients who present with spinal instability and neurologic deficits are more likely to have open procedures and prolonged hospital stays.[13] Follow-up quality of life, the Karnofsky performance status (KPS) scores, and survival rates are lower in patients with VM treated in emergency hours, who presented with acute neurologic deterioration and unstable spine.[10] Long-segment percutaneous fixation followed by early radiotherapy is reported to be associated with an improved quality of life in patients, while providing stability to the spine.[14] Patients with spinal instability following metastasis may respond inadequately to palliative radiotherapy as well, and hence, timely detection and referral to a spine surgeon or a neurosurgeon is important.[15] Patients with gross mechanical instability as per the SINS criteria are reported to have higher 30-day postoperative mortality.[16] However, before proceeding with any surgical intervention, it is essential to have a minimum period of 3 months[17] of estimated survival of the patient. A modified Tokuhashi score of less than 8 or a Tomita score of 7 generally predicts poor outcomes among patients with spinal metastasis, and it is recommended to offer palliative treatment only in such patients.[18]

In a recent paper published by van Tol et al.,[15] patient referral pattern was reconstructed and the delay was divided into four categories – patient delay (onset of symptoms until medical consultation), diagnostic delay (medical consultation until diagnosis), referral delay (diagnosis until referral to a spine surgeon), and treatment delay (referral to a spine surgeon until treatment). The authors observed a median delay of 99 days, with diagnostic delay (21.5 days) and patient delay (19 days) being the two most important causes of delay in patients receiving surgical treatment for metastatic disease. Published literature highlights the fact that more awareness has to be built around spinal metastasis, both among the patients and the treating/referring physicians alike,[19] considering that the burden is likely to increase in coming years with an increase in life expectancy and an increase in the incidence of malignancies. The Netherlands Comprehensive Cancer Organization has identified five “red flags” that are indicative of metastatic spinal disease, and these include new onset of back pain, progressive back pain, nocturnal back pain, pain on palpation, and poor general health (e.g., weight loss).[20] Documentation of these red flags by healthcare workers across primary, secondary, and tertiary healthcare centers may help to reduce delays in referrals in patients with metastatic spinal disease.[20] In various centers, surgical consultation for metastatic spine disease treated with radiation is low,[16],[19] and a multidisciplinary approach to such patients with timely surgical consults is likely to improve outcomes in them.

In spinal metastasis, artificial intelligence has shown a promising role in image processing, diagnosis, decision support, treatment assistance, and prognostic outcomes[21] and is expected to play a significant role in decision-making in the future. Artificial intelligence can analyze and interpret pertinent parameters from magnetic resonance imaging (MRI) and other imaging techniques. A deep learning model developed by Hallinan et al.[22] for automated classification of metastatic spinal cord compression or epidural disease on MRI using the Bilsky classification had good concordance with specialist readers. Radiomic modeling and machine learning can be used to predict vertebral compression fractures in patients with spinal metastasis following radiation therapy. Prediction models can be developed based on the SINS classification, and these can be used to follow-up and promptly treat patients.[22] There is optimism that such prediction models can delay referrals and patients can reach neurosurgeons/spine surgeons well within time and avoid surgery during emergency hours following acute neurologic deterioration.[21]

Patients with spinal metastasis and unstable vertebral column need to be identified promptly and referred to a spine surgeon or a neurosurgeon as delay in treatment with surgery done during emergency hours following acute neurologic deterioration is associated with more intraoperative complications and an overall worse prognosis compared to those of patients who are operated in a planned manner with the opinion of a multidisciplinary tumor board. Time to referral is critical in unstable VM and a protocol-based approach to such patients is important for a better patient outcome.

 » References Top

Abrahm JL. Assessment and treatment of patients with malignant spinal cord compression. J Support Oncol 2004;2:377-88, 391; discussion 391-393, 398, 401.  Back to cited text no. 1
Brooks FM, Ghatahora A, Brooks MC, Warren H, Price L, Brahmabhatt P, et al. Management of metastatic spinal cord compression: Awareness of NICE guidance. Eur J Orthop Surg Traumatol Orthop Traumatol 2014;24(Suppl 1):S255-9.  Back to cited text no. 2
Al-Qurainy R, Collis E. Metastatic spinal cord compression: Diagnosis and management. BMJ 2016;353:i2539.  Back to cited text no. 3
Harel R, Angelov L. Spine metastases: Current treatments and future directions. Eur J Cancer Oxf Engl 1990 2010;46:2696-707.  Back to cited text no. 4
Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. Lancet Lond Engl 2005;366:643-8.  Back to cited text no. 5
Quraishi NA, Rajagopal TS, Manoharan SR, Elsayed S, Edwards KL, Boszczyk BM. Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression. Eur Spine J 2013;22:1383-8.  Back to cited text no. 6
Weber MH, Burch S, Buckley J, Schmidt MH, Fehlings MG, Vrionis FD, et al. Instability and impending instability of the thoracolumbar spine in patients with spinal metastases: A systematic review. Int J Oncol 2011;38:5-12.  Back to cited text no. 7
Fox S, Spiess M, Hnenny L, Fourney DR. Spinal Instability Neoplastic Score (SINS): Reliability among spine fellows and resident physicians in orthopedic surgery and neurosurgery. Global Spine J 2017;7:744-8.  Back to cited text no. 8
Versteeg AL, van der Velden JM, Verkooijen HM, van Vulpen M, Oner FC, Fisher CG, et al. The effect of introducing the spinal instability neoplastic score in routine clinical practice for patients with spinal metastases. Oncologist 2016;21:95-101.  Back to cited text no. 9
van Tol FR, Suijkerbuijk KPM, Choi D, Verkooijen HM, Oner FC, Verlaan J-J. The importance of timely treatment for quality of life and survival in patients with symptomatic spinal metastases. Eur Spine J 2020;29:3170-8.  Back to cited text no. 10
Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al. The NOMS framework: Approach to the treatment of spinal metastatic tumors. Oncologist 2013;18:744-51.  Back to cited text no. 11
Poortmans P, Vulto A, Raaijmakers E. Always on a Friday? Time pattern of referral for spinal cord compression. Acta Oncol 2001;40:88-91.  Back to cited text no. 12
van Tol FR, Massier JRA, Frederix GWJ, Öner FC, Verkooijen HM, Verlaan J-J. Costs associated with timely and delayed surgical treatment of spinal metastases. Global Spine J 2022;12:1661-6.  Back to cited text no. 13
Bernard F, Lemée J-M, Lucas O, Menei P. Postoperative quality-of-life assessment in patients with spine metastases treated with long-segment pedicle-screw fixation. J Neurosurg Spine 2017;26:725-35.  Back to cited text no. 14
van Tol FR, Versteeg AL, Verkooijen HM, Öner FC, Verlaan J-J. Time to surgical treatment for metastatic spinal disease: Identification of delay intervals. Global Spine J 2023;13:316-23.  Back to cited text no. 15
Sullivan PZ, Albayar A, Ramayya AG, McShane B, Marcotte P, Malhotra NR, et al. Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment. J Neurosurg Spine 2020;1-8. doi: 10.3171/2019.11.SPINE19775.  Back to cited text no. 16
Choi D, Crockard A, Bunger C, Harms J, Kawahara N, Mazel C, et al. Review of metastatic spine tumour classification and indications for surgery: The consensus statement of the Global Spine Tumour Study Group. Eur Spine J 2010;19:215-22.  Back to cited text no. 17
Aoude A, Amiot L-P. A comparison of the modified Tokuhashi and Tomita scores in determining prognosis for patients afflicted with spinal metastasis. Can J Surg2014;57:188-93.  Back to cited text no. 18
McQuail PM, McCartney BS, Baker JF, Jaadan M, McCabe JP. Management of metastatic spinal cord compression in Ireland: Are surgeons overlooked? Int J Spine Surg 2018;12:428-33.  Back to cited text no. 19
van Tol FR, Kamm IMLP, Versteeg AL, Suijkerbuijk KPM, Verkooijen HM, Oner C, et al. The use of red flags during the referral chain of patients surgically treated for symptomatic spinal metastases. Neurooncol Pract 2023;10:301-6.  Back to cited text no. 20
Ong W, Zhu L, Zhang W, Kuah T, Lim DSW, Low XZ, et al. Application of artificial intelligence methods for imaging of spinal metastasis. Cancers (Basel) 2022;14:4025.  Back to cited text no. 21
Hallinan JTPD, Zhu L, Zhang W, Lim DSW, Baskar S, Low XZ, et al. Deep learning model for classifying metastatic epidural spinal cord compression on MRI. Front Oncol 2022;12:849447.  Back to cited text no. 22


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