INTRODUCTION
Advancements in cancer treatment have extended survival, with shortened hospital stays and a shift toward outpatient treatment.[ 1 ] Consequently, the incidence of metastatic bone tumors, as well as skeletal-related events such as pain and pathological fractures, has increased.[ 2 , 3 ]
The spine is the most common site for metastasis, often from breast, lung, and prostate cancers.[ 4 , 5 , 6 ] Metastatic spinal tumors can cause pathological fractures, leading to impaired mobility and neurological function and significantly impacting activities of daily living, quality of life (QOL), and performance status (PS).[ 4 , 7 , 8 , 9 ] Treatment options for metastatic spinal tumors include palliative radiotherapy, bone-modifying agent administration, and surgery. Surgery goals include tissue sampling for diagnosis, spinal cord decompression, and spinal stabilisation and reconstruction to alleviate pain.[ 10 ] Previous studies have reported that decompressive surgery followed by palliative radiotherapy showed better outcomes than palliative radiotherapy alone.[ 11 , 12 ]
Posterior spinal fixation surgery can stabilize the spine, alleviate pain, and improve QOL.[ 10 , 13 , 14 , 15 ] Minimally invasive spine stabilization (MISt) using percutaneous pedicle screws and balloon kyphoplasty (BKP) to fill the vertebral body with bone cement has recently become increasingly common, given their advantage of shorter hospital stays.[ 8 , 11 , 16 , 17 , 18 ]
However, surgery for metastatic spinal tumors remains primarily palliative, and its role in patients with short life expectancies remains controversial. Therefore, we aimed to investigate the clinical course and changes in PS among patients who underwent posterior spinal fixation surgery for spinal metastases, hypothesising that surgery would improve PS and QOL.
SUBJECTS AND METHODS
Ethics
This study was approved by the Ethics Committee of Kyushu Rosa Hospital (approval number 22-15) and conducted in accordance with the ethical guidelines of the Declaration of Helsinki (1975). This retrospective case-series study was conducted using the opt-out method for participants. Informed consent was obtained from all the participants included in this study.
Methods
We retrospectively reviewed the cases of patients with metastatic spinal tumors, including those arising from hematological malignancies, treated at XXX Hospital from April 2017 to April 2024. We excluded the cases of patients who underwent only biopsy and/or laminectomy and cases of patients who died due to other diseases. The final cohort included 33 cases (25 male and eight female patients) of patients who underwent posterior spinal fixation surgery. The following parameters were assessed: Age at surgery, primary tumour type, metastatic site, Spinal Instability Neoplastic Score (SINS)[ 19 ] of the surgical site, new Katagiri score,[ 20 ] Tokuhashi score,[ 21 ] New England Spinal Metastasis Score (NESMS),[ 22 , 23 , 24 ] surgical method, PS before surgery and 2 weeks postsurgery, modified Frankel Classification[ 25 ] before surgery and 2 weeks postsurgery, perioperative complications, presence or absence of preoperative and postoperative palliative radiotherapy, use of bone-modifying agents, follow-up period, and final outcome.
Statistical analysis
For categorical variables, Fisher’s exact test was used to compare any two groups. Kaplan–Meier survival curves were generated and analyzed for group comparisons using the log-rank test. Statistical analyses were conducted using JMP ® 17 (SAS Institute Inc., Cary, NC, USA), with P < 0.05 considered statistically significant.
RESULTS
Clinicopathological results
The clinicopathological factors of the patients are summarized in Table 1 . There were 25 males (76%) and eight females (24%), with an age range of 49–87 years (median: 68 years). Primary tumors were lung cancer in 10 (30%), prostate cancer in nine (27%), kidney cancer in four (12%), malignant lymphoma in three (9%), colorectal cancer in two (6%), multiple myeloma in two (6%), and stomach, liver, and ureteral cancer in one (3%) case each, respectively. The surgical site was the cervical spine in four (12%), the thoracic spine in 14 (43%), the thoracolumbar transition area in 10 (30%), and the lumbar and sacral spine in five cases (15%), respectively. SINS of the surgical site were ≥13 points in 12 (36%), 7–12 points in 20 (61%), and ≤6 points in one (3%) case, respectively. The preoperative new Katagiri score was 0–3 points in 10 (30%), 4–6 points in 21 (64%), and 7–10 points in two (6%) cases, respectively. The Tokuhashi score was 0–8 points in 19 (58%), 9–11 points in 11 (33%), and 12–15 points in three (9%) cases, respectively. NESMS was 0–2 points in 21 cases (64%) and 3–4 points in 12 cases (36%), respectively. The surgical methods were open spinal fusion in 16 (49%), MISt in 15 (45%), and BKP in two (6%) cases, respectively. The preoperative PS score was 0–2 in 23 (70%) and 3–4 in 10 (30%) cases, respectively. The preoperative modified Frankel classification was Grade A in three (9%), Grade B in two (6%), Grade C in three (9%), Grade D in nine (27%), and Grade E in 16 (49%) cases, respectively. The postoperative PS score was 0–2 in 25 (76%) and 3–4 in eight (24%) cases. Furthermore, the postoperative modified Frankel classification was Grade A in three (9%), Grade B in two (6%), Grade C in one (3%), Grade D in 11 (33%), and Grade E in 16 (49%) cases, respectively [ Table 2 ]. The mean operative time and blood loss were 142 min and 130 mL, respectively. Postoperative complications included one case of screw malposition and two cases of adjacent vertebral fractures. Twenty-five patients received preoperative and/or postoperative radiation therapy, and bone-modifying agents were administered to 25 patients postoperatively. The median survival time postsurgery was 25 months, with approximately half of the cases resulting in death within 1 year [ Figure 1 ].
Table 1
Characteristics and clinicopathologic factors of study participants
SINS - Spinal instability neoplastic score; BKP - Balloon kyphoplasty; NESMS - New England spinal metastasis score; MISt - Minimally invasive spine stabilization
| Characteristic | Cases (%) |
| Sex | |
| Men | 25 (76) |
| Women | 8 (24) |
| Age (years), median (minimum–maximum) | 68 (49–87) |
| <68 | 15 (45) |
| ≥68 | 18 (55) |
| Primary tumor | |
| Lung | 10 (30) |
| Prostate | 9 (27) |
| Kidney | 4 (12) |
| Malignant lymphoma | 3 (9) |
| Colon | 2 (6) |
| Myeloma | 2 (6) |
| Stomach, liver, urethra | 1 (3) |
| Surgical site | |
| Cervical vertebrae | 4 (12) |
| Thoracic vertebrae | 14 (42) |
| Thoracic-lumbar junction | 10 (30) |
| Lumbar and sacral vertebrae | 5 (16) |
| SINS | |
| 0–6 | 1 (3) |
| 7–12 | 20 (61) |
| 13–18 | 12 (36) |
| Operation | |
| Open | 16 (49) |
| MISt | 15 (45) |
| BKP | 2 (6) |
| New Katagiri score | |
| 0–3 | 10 (30) |
| 4–6 | 21 (64) |
| 7–10 | 2 (6) |
| Tokuhashi score | |
| 0–8 | 19 (58) |
| 9–11 | 11 (33) |
| 12–15 | 3 (9) |
| NESMS | |
| 0–2 | 21 (64) |
| 3–4 | 12 (36) |
Table 2
Changes in performance status and Frankel classification for each patient
PS - Performance status; BKP - Balloon kyphoplasty; PPS - Percutaneous pedicle screw
| Age | Sex | Primary tumor | Surgical site | Operation | Preoperative PS | Postoperative PS | Preoperative Frankel grade | Postoperative Frankel grade | Survival duration |
| 65 | Male | Lung | C7-Th5 | PPS | 3 | 3 | D3 | D3 | 2 |
| 69 | Male | Stomach | Th11-L3 | PPS | 2 | 1 | E | E | 25 |
| 67 | Female | Kidney | Th10-S1 | PPS | 3 | 2 | A2 | A2 | 11 |
| 59 | Male | Lung | C2-7 | Open | 3 | 3 | D2 | D2 | 5 |
| 73 | Male | Prostate | L2-4 | Open | 1 | 1 | E | E | 2 |
| 63 | Male | Lung | L3-S2 | Open | 1 | 0 | E | E | 30 |
| 60 | Female | Lung | C5-Th5 | Open | 2 | 1 | C2 | D2 | 54 |
| 72 | Male | Prostate | L2-S2 | PPS | 2 | 1 | C2 | D1 | 7 |
| 62 | Male | Prostate | Th1-5 | Open | 1 | 1 | E | E | 56 |
| 87 | Male | Prostate | Th3-7 | Open | 2 | 1 | E | E | 36 |
| 71 | Male | Lymphoma | Th6-10 | Open | 1 | 1 | E | E | 52 |
| 71 | Female | Kidney | Th8-L2 | PPS | 2 | 1 | D3 | D3 | 39 |
| 70 | Female | Lymphoma | Th3-8 | Open | 4 | 4 | A | A | 2 |
| 56 | Male | Lung | C5-Th6 | Open | 1 | 0 | E | E | 33 |
| 62 | Male | Lung | Th9-L2 | PPS | 1 | 1 | E | E | 6 |
| 68 | Male | Liver | Th9-L3 | PPS + laminectomy | 4 | 4 | A | A | 10 |
| 65 | Male | Kidney | C3-7 | Open | 2 | 1 | D3 | D3 | 18 |
| 67 | Male | Lung | Th6-10 L2-5 | PPS | 2 | 2 | D3 | D3 | 2 |
| 72 | Female | Lung | L2-S1 | PPS | 2 | 2 | D1 | D0 | 5 |
| 77 | Male | Myeloma | C3-6 | Open + laminectomy | 1 | 0 | E | E | 45 |
| 81 | Male | Prostate | Th2-6 | Open | 1 | 0 | E | E | 20 |
| 80 | Female | Urethra | Th10-L4 | PPS | 3 | 3 | D3 | D3 | 3 |
| 85 | Male | Prostate | Th12-L1 | BKP | 3 | 3 | D3 | D3 | 7 |
| 63 | Male | Kidney | Th10-L2 | PPS | 1 | 1 | E | E | 29 |
| 78 | Male | Prostate | Th5-9 | Open | 4 | 4 | B | B | 4 |
| 52 | Male | Lymphoma | Th9-L1 | PPS | 2 | 1 | E | E | 25 |
| 69 | Female | Myeloma | Th8-12 | Open | 4 | 4 | B | B | 51 |
| 66 | Female | Colon | C5-Th3 | Open | 2 | 2 | C1 | C1 | 4 |
| 68 | Male | Prostate | C4-Th2 | Open | 1 | 0 | E | E | 25 |
| 49 | Male | Lung | L4-S2 | PPS | 2 | 1 | D3 | D3 | 25 |
| 80 | Male | Prostate | L1 | BKP | 2 | 2 | E | E | 5 |
| 60 | Male | Colon | Th6-10 | PPS | 1 | 1 | E | E | 4 |
| 87 | Male | Lung | Th12-L4 | PPS | 3 | 2 | E | E | 6 |
Statistical results
Among the 10 cases with preoperative PS 3–4, postoperative improvement was limited to one case. In contrast, among the 23 cases with preoperative PS 0–2, 13 showed postoperative improvement. Cases with preoperative PS 0–2 demonstrated statistically significant postoperative improvement compared with those with PS 3–4 ( P = 0.0209).
Improvement in paralysis was limited to three cases: Two cases of Frankel Grade C2 and one case of Grade D1. No improvement was observed in three cases of Grade A and two cases of Grade B, both presenting severe paralysis. There was no significant difference in paralysis improvement between the A/B group and the C/D/E group ( P = 1.0000).
Survival rates were compared across various prognostic scores. Regarding the new Katagiri score, lower scores were associated with longer survival periods, while higher scores corresponded to shorter survival periods. Significant differences were observed in pairwise comparisons between groups (score 0–3 vs. 4–6 [ P = 0.0113]; score 4–6 vs. 7–10 [ P = 0.0010]; score 0–3 vs. 7–10 [ P = 0.0074]) [ Figure 2a ]. Similarly, in the NESMS, cases with scores of 0–2 showed significantly longer survival periods than those with scores of 3–4 ( P = 0.0222) [ Figure 2b ]. No significant differences in survival periods were observed among the different scores of the Tokuhashi score (data not shown).
Furthermore, 17 patients survived for ≥12 months, while 16 died within 12 months. Of the 17 patients who survived for ≥12 months, 12 showed improvement in PS after surgery. In contrast, only 2 of the 16 patients who died within 12 months showed improvement in PS after surgery. Patients who survived for ≥12 months showed statistically significant PS improvement ( P = 0.0209).
Case presentation
A 69-year-old male was referred for a suspected metastatic spinal tumor after undergoing imaging studies owing to lower back and leg pain. Imaging (lumbar X-rays and computed tomography [CT] scan) revealed a neoplastic lesion in the first lumbar vertebra with severe spinal canal stenosis. A metastatic spinal tumor was suspected; however, a whole-body CT revealed no tumorous lesions in other areas. The SINS was 12 points, indicating potential instability. The PS was two, with no lower limb paralysis (Frankel Grade E), but back and bilateral leg pain was worsening with movement.
Open biopsy and MISt from the 11 th thoracic vertebra to the third lumbar vertebra were performed for diagnosis and local treatment [ Figure 3 and Table 2 ]. Two weeks postsurgery, pain was reduced, independent walking was possible, and PS improved to one. Pathological diagnosis revealed gastric cancer, and chemotherapy was subsequently initiated in the Department of Gastroenterology. For spinal metastasis, palliative radiation therapy (30 Gy in 10 fractions) and a bone-modifying agent were started.
![Figure 3 Case presentation [ Table 2 ]. The white arrows indicate pathological fracture of the first lumbar vertebra (L1) on the X-ray image. CT: Computed tomography, MRI: Magneti…](/library/4479583/assets/b2622bd3596fc77bf206959caf0b4057886160a30bf39210d1f7fbc7ad136cc6.jpg/)
The patient died 25 months postsurgery because of tumor death without surgical complications such as screw loosening observed until death.
DISCUSSION
This retrospective study evaluated the postoperative outcomes of posterior spinal fixation surgery in patients with metastatic spinal tumors and examined PS improvement and paralysis progression. Results indicate significant PS improvement in those with a preoperative PS of 0–2, whereas patients with a PS of 3–4 showed limited benefit. While surgery can enhance QOL by stabilizing the spine and relieving pain, careful patient selection is crucial. The study highlights the importance of early surgical intervention for maximizing benefits while emphasizing the need for comprehensive prognostic evaluation in patients with poor initial PS.
Preventing skeletal-related events caused by metastatic bone tumors is crucial for maintaining and improving the QOL of patients with cancer. Metastatic spinal tumors are particularly common and can significantly impair QOL by causing pain and neurological disorder.[ 9 , 10 , 26 ] The primary reasons for performing spinal fusion surgery include alleviating pain from spinal instability, improving or preventing neurological disorder progression, enabling chemotherapy by improving PS, and ultimately extending the patient’s survival period.[ 9 , 16 , 17 , 26 ] However, the primary goal of treatment for metastatic spinal tumors remains palliation, and the decisions regarding treatment approach and timing vary. It is determined case-by-case, considering the individual patient’s condition. When considering palliative surgery for patients with limited life expectancy, factors such as the risk of complications, expected benefits, and medical costs must be carefully evaluated. Surgical intervention is justified only if the benefits clearly outweigh the risks. Consequently, the significance of palliative surgery for patients with short life expectancy remains controversial.[ 27 ] Prognostic scoring systems such as the new Katagiri score, Tokuhashi score, and NESMS have been found useful in spinal metastasis assessment. Surgical intervention should be carefully considered for patients with a predicted prognosis of less than 3 months.[ 10 , 20 , 22 , 23 , 24 , 28 ] However, some studies advocate for proactive palliative surgery, arguing that improving functional outcomes through surgery could increase opportunities for postoperative adjuvant therapies and potentially extend survival indirectly.[ 29 ]
Nakanishi et al . reported significant improvement in mean PS from 2.5 ± 1.3 preoperatively to 1.7 ± 1.3 postoperatively, suggesting that MISt can improve PS.[ 17 ] Improvement in postoperative PS was also observed in the present study, particularly in patients with preoperative PS of 0–2 compared with those with PS of 3–4. This finding was limited to evaluation at 2 weeks postoperatively; however, the results indicated that patients with preoperative PS of ≤2, who have higher activity levels, can expect improvement in PS. However, for patients with poor activity levels (PS 3–4), spinal fusion surgery did not lead to substantial early improvement in PS. Regarding improvement in neurological deficits, patients with severe motor paralysis, particularly those classified as Frankel A or B, showed no improvement in paralysis, consistent with previous findings that severe paralysis rarely improves postsurgery.[ 30 ] These results suggest that preoperative severity of paralysis strongly determines postoperative activity levels. In addition, the finding of limited improvement in paralysis may also reflect that patients with poor PS are unlikely to see improvements in their PS.
Ensuring that individual patient backgrounds are fully considered, spinal fusion surgery may be performed for pain relief purposes. However, the degree of PS improvement varies based on the patient’s initial PS grade, and postoperative effectiveness may be limited in cases with severe PS decline. This consideration is crucial when assessing surgical eligibility. While previous reports have demonstrated postoperative improvements in PS and QOL, further research is needed to analyze the changes per individual PS score.
Regarding prognostic scoring systems, both the new Katagiri score and NESMS demonstrated statistically significant differences in prognosis within their respective scores, proving their utility as tools for prognostic assessment and reinforcing their extreme importance in surgical decision-making. Notably, patients who survived for more than 1 year showed significantly improved PS compared with those who survived less than a year, emphasizing that prognostic prediction is a crucial factor in treatment consideration.
This study has some limitations. First, while it provides a comprehensive overview of spinal fixation surgery for spinal metastases, it lacks uniformity owing to several factors, including mixed cancer types, inclusion of the entire spine regions (cervical to sacral), a mixture of single and multiple metastases cases with varying fixation ranges, inconsistent use of palliative radiation therapy and bone-modifying agents, and inclusion of two cases of additional laminectomy. Thus, the study lacks consistency. Second, the short follow-up period (2 weeks postsurgery) limits the findings to a short-term assessment. Finally, evaluating postoperative pain is challenging, as many patients undergoing palliative treatment receive opioid medications both preoperatively and postoperatively. This makes it difficult to attribute pain relief solely to the surgery, and this aspect was not evaluated in our study.
CONCLUSION
This study demonstrated that spinal fixation surgery for patients with metastatic spinal tumors can improve postoperative PS. Notably, patients with PS 0–2 showed significantly better postoperative PS improvement than those with PS 3–4, suggesting that surgical intervention is preferable before the patient’s general condition deteriorates. However, surgery may still be necessary for patients with lower PS for purposes such as pain relief or prevention of fractures and paralysis. Therefore, comprehensive decision-making is essential to optimize the patient outcomes.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors would like to thank Editage for the English language review.
Funding Statement
This research was supported by research funds to promote the hospital functions by the Japan Organization of Occupational Health and Safety.
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