Clinical-Radiological Heterogeneity Within Intermediate Spinal Instability Neoplastic Scores (7-12): Factors Associated with Instrumented Stabilization in a Surgical Cohort.
Jul 2026· World Neurosurgery· Vol 213, pp.
125183
· 0 citations
Medicine
TL;DR
How the intermediate Spinal Instability Neoplastic Score (SINS 7-12) category was operationalized in a real-world surgical spine oncology practice and identify preoperative factors associated with instrumented stabilization are described are described.
Abstract
Objective
To describe how the intermediate Spinal Instability Neoplastic Score (SINS 7-12) category was operationalized in a real-world surgical spine oncology practice and identify preoperative factors associated with instrumented stabilization.
Methods
Adults surgically treated for histopathologically confirmed spinal metastases at a single center between 2020 and 2025 were retrospectively analyzed. Patients required complete clinical and imaging data for SINS and epidural spinal cord compression (ESCC) assessment. Intermediate SINS cases were compared according to instrumentation status. Total SINS discrimination was assessed using receiver operating characteristic analysis and exploratory multivariable models.
Results
Of 105 surgical cases, 103 had complete SINS data: 11 were stable, 78 intermediate, and 14 unstable. Among intermediate SINS cases, 61/78 (78%) underwent instrumented stabilization and 17/78 (22%) decompression alone. Stabilized patients more often had symptom duration >14 days (93% vs 53%, p < 0.001), Frankel grade E (62% vs 18%, p = 0.002), and ECOG 0-II (79% vs 41%, p = 0.005). Total SINS did not differ between groups (median 10 vs 10; p = 0.79) and showed limited discrimination (AUC 0.52; 95% CI 0.36-0.67). In exploratory multivariable analyses, symptom duration >14 days and Frankel grade E were associated with stabilization, whereas ≥3 spinal metastases were associated with lower likelihood of instrumentation. High-grade ESCC was associated with stabilization in sensitivity analysis, although precision was limited.
Conclusions
Intermediate SINS represents a clinically heterogeneous gray zone. In our institutional practice, stabilization decisions were not based on total SINS alone but on integrated clinical-radiological assessment, supporting avoidance of rigid SINS cutoffs.
Complication reporting in spinal tumor surgery remains inconsistently defined. We aimed to quantify the incidence, severity, and spectrum of early (≤ 30 days) postoperative adverse events (AEs) in spinal tumor surgery and to identify predictors of overall and serious complications using standardized severity grading. We analyzed prospective data from 156 patients undergoing spinal tumor surgery for mixed primary and metastatic pathologies between 2023 and 2025. Intra- and extradural lesions were included. AEs were classified according to the Clavien-Dindo system, and risk factors were identified using logistic regression. The age-adjusted Charlson comorbidity index (ACCI) was used to assess comorbidity burden. Any postoperative AE occurred in 16.7% of cases, and serious complications (Clavien-Dindo ≥ III) occurred in 7.1%. Surgery-related events predominated (14.7%). Stratified analysis revealed differences between tumor subgroups, with the highest complication rates observed in intramedullary tumors, primarily driven by neurological deficits. The ACCI was the strongest predictor of both overall (p = 0.006) and serious complications (p = 0.001), corresponding to a 20%-39% risk increase per point. Emergency surgery and advanced age were associated with serious complications, while operative duration correlated modestly with overall AEs. Mortality within 30 days was 1.9%. AEs were dominated by neurological and surgery-related complications. Complication profiles differed according to tumor location, reflecting underlying surgical and biological differences. Comorbidity burden and urgency emerged as predictors for AEs in general. These findings underscore the need for structured preoperative risk stratification, timely elective referral, and standardized AE reporting to improve safety and comparability across spinal tumor surgery studies.
M. Ivren, P. Dao Trong, Maximilian Klass et al.· International Journal of Can...· 0 citations
Objective
To compare clinical and radiological outcomes of anterior (ACSS) and posterior cervical spine surgery (PCSS) in patients with single-level metastatic cervical spinal tumor (MCST).
Methods
We retrospectively reviewed 27 patients with single-level MCST treated at a single institution between January 2001 and February 2024, categorized into ACSS (n = 16) and PCSS (n = 11) groups. Clinical outcomes were assessed using the Eastern Cooperative Oncology Group (ECOG) performance status, Nurick scale, and visual analog scale (VAS) for neck pain. Radiological parameters-C2-C7 cervical lordosis, sagittal vertical axis, T1 slope, neck tilt, and segmental Cobb angle (SCA)-were evaluated preoperatively, at 1 month postoperatively, and at final follow-up. Baseline bone quality (adjacent vertebral Hounsfield units), bone-modifying agent use, and adjuvant radiotherapy/systemic therapy were also assessed. Index vertebral collapse was defined as a decrease in SCA exceeding 10° from 1 month postoperatively to final follow-up. Time to kyphotic progression was compared using Kaplan-Meier and Cox proportional hazards analyses.
Results
Short-term clinical outcomes did not differ between groups, and both groups achieved comparable kyphosis correction at 1 month postoperatively. However, from 1 month to final follow-up, SCA loss was significantly greater in ACSS (-15.6° ± 7.8° vs -5.5° ± 4.5°; p < 0.001), and index vertebral collapse occurred more frequently in ACSS (81.3% vs 18.1%; p = 0.003). Compensatory changes in T1 slope and neck tilt were significantly greater in ACSS, suggesting greater cranio-cervical adaptation. The median time to SCA decrease exceeding 10° was shorter in ACSS (0.4 vs 2.0 years; log-rank p = 0.0018), and multivariate Cox analysis confirmed a significantly lower hazard of kyphotic progression in PCSS. Operative time was shorter in PCSS (199.1 ± 17.6 vs 245.8 ± 22.5 minutes; p < 0.001). Adjacent vertebral bone density and adjuvant therapy were balanced between groups, although all PCSS cases were performed in the recent era.
Conclusion
While short-term clinical outcomes were comparable, PCSS was associated with slower kyphotic progression and a lower rate of index vertebral collapse, suggesting more durable radiographic stability that warrants confirmation in larger prospective studies.
Subum Lee, Seungjun Ryu, Sang Hoon Hwang et al.· Journal of Korean Neurosurgi...· 0 citations
Introduction Recurrence after radiologically confirmed gross total resection (GTR) of non-functioning pituitary macroadenomas (NFPMAs) remains a relevant clinical challenge. Research question Which preoperative and perioperative factors are associated with recurrence after radiological GTR of NFPMAs? Material and methods We retrospectively analyzed 212 patients who underwent MRI-guided transnasal transsphenoidal surgery for histologically confirmed NFPMAs between 2007 and 2023 at a single tertiary neurosurgical center. Among these, 94 patients were classified as having radiological GTR based on postoperative MRI and longitudinal interdisciplinary review; 62 showed no recurrence and 32 developed recurrence during follow-up. Demographic variables, tumor configuration, suprasellar and cavernous sinus extension, surgical characteristics, histopathology, volumetric measurements, and pre-/postoperative cortisol levels were evaluated. Tumor volumes were manually segmented. Statistical comparisons included Mann–Whitney U tests, chi-squared tests, and ROC analysis. Results Patients in the recurrence subgroup were significantly younger (mean age, 51.2 vs. 57.1 years; p = 0.008) and had significantly larger preoperative tumor volumes (10.45 cm3 vs. 5.54 cm3; p = 0.022), higher Hardy grades (p < 0.001), higher Knosp grades (p = 0.009), and more frequent suprasellar extension (90.6% vs. 64.5%; p = 0.014). ROC analysis identified a preoperative volume cutoff of 9.22 cm3 (AUC 0.667). Surgical approach, histological subtype, and preoperative visual field deficits were not significantly associated with recurrence. Postoperative cortisol changes differed between groups (p = 0.035). Discussion and conclusion Larger tumor volume and more invasive radiological configuration were associated with recurrence despite radiological GTR. These parameters may help refine postoperative surveillance strategies. Prospective validation is warranted.
V. Eisenkolb, P. Schneider, C. Negwer et al.· Brain and Spine· 0 citations
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVE
To identify patient-related, operative, radiographic, and bone quality predictive risk factors associated with proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery and evaluate diagnostic performance of opportunistic CT-derived bone quality metrics.
SUMMARY OF BACKGROUND DATA
PJF is a severe complication of ASD correction associated with pain, deformity progression, and reoperation. While numerous risk factors have been proposed, reported associations are inconsistent, and clinical utility of opportunistic bone quality assessment remains uncertain.
METHODS
PubMed, Embase, and CENTRAL were searched from inception to January 2026. Observational studies reporting PJF after ASD surgery with extractable comparative data were included. Random-effects meta-analyses were used. Diagnostic accuracy of Hounsfield unit measurements was summarized using pooled sensitivity, specificity, and area under curve (AUC).
RESULTS
Twenty-eight studies encompassing 4560 patients were included, of whom 1064 (23.3%) developed PJF. Patients with PJF were older (MD 2.59 y, P <0.001) and had worse baseline disability and pain. Binary osteoporosis status was not consistently associated with PJF, though continuous bone measures were predictive, including lower DEXA T-scores (MD -0.55, P <0.001), and CT attenuation at upper instrumented vertebra (MD -28.97 units, P <0.0001) and immediately cranial adjacent vertebra (MD -32.67 units, P <0.0001). Radiographically, PJF was associated with greater preoperative sagittal misalignment, including higher pelvic tilt and sagittal vertical axis, lower lumbar lordosis, and greater pelvic incidence-lumbar lordosis mismatch. Fusion length and upper instrumented level (dichotomized at T10) were not significantly associated with failure. Hounsfield units demonstrated good diagnostic performance (pooled AUC 0.86).
CONCLUSION
PJF after ASD surgery reflects the interaction between sagittal misalignment, correction strategy, and junctional structural capacity. Continuous bone quality measures, particularly opportunistic Hounsfield unit assessment, show potential for risk stratification and may inform targeted preventive strategies in biologically vulnerable patients, pending prospective validation.
Shaan Patel, S. Nischal, Griffin W. White et al.· Spine· 0 citations
Objective We aimed to study how patient frailty, pre-operative tumor volume, and symptom burden collectively impact primary management choice, postoperative complication rates, and outcomes in the treatment of petroclival meningiomas. Methods We retrospectively analyzed a cohort of 73 patients diagnosed with petroclival meningiomas at Emory Healthcare from 2000 to 2022. Frailty was quantified with the 5-item modified frailty index (mFI-5). Tumor volume was measured from pre-operative MRI with 3D Slicer. Tumor-related symptoms were clustered into five domains (visual, vestibulocochlear, sensory, motor, headache) and summed into a composite Symptom Burden Score (SBS). Primary management was categorized as surgical resection versus conservative therapy (serial imaging or radiotherapy). Multivariable logistic regression evaluated predictors of treatment selection; a second model examined 30-day postoperative complications in surgical patients. Linear mixed-effects models (LMM) tracked SBS, and domain-specific generalized linear mixed-effects models (GLMM) assessed symptom resolution at 3, 6, and 12 months, controlling for both frailty and treatment approach. Sensitivity analyses dichotomized frailty (mFI-5 = 0 vs. ≥1). Significance threshold: two-sided p < 0.05. Results Surgically treated tumors were larger than conservatively managed lesions (median 14.3 cm3 vs. 8.9 cm3; p = 0.018), and management choice varied by frailty strata (χ2 = 12.86, p = 0.015). In multivariable analysis, neither tumor volume (OR 1.04, 95% CI 0.97–1.11) nor mFI-5 score (OR 0.56, 95% CI 0.20–1.82) independently predicted operative selection. Thirty day complication rates increased with frailty but mFI-5 was not an independent risk factor (OR 0.51, 95% CI 0.22–1.18). Mean patient level SBS declined in both groups at 12 months (conservative −28%; surgical −8%), with a marginally significant interaction between treatment approach and frailty (p = 0.072). Symptom domain analysis showed significant improvement in visual and vestibulocochlear deficits irrespective of management, whereas conservative therapy was associated with poorer motor deficit recovery (p = 0.025). Conclusions Preoperative tumor volume and frailty jointly influence treatment approach, yet neither metric alone dictates management decision when considered together. Perioperative risk-reduction protocols may mitigate frailty-associated morbidity. While most neurologic symptoms improve within a year, frailer patients have attenuated symptomatic improvement, in addition to domain-specific differences.
Rommi Kashlan, Razan R. Faraj, Hithardhi Duggireddy et al.· Frontiers in Surgery· 0 citations
Study Design Retrospective Cohort Study using Nested Matched Case-Control Analysis. Objectives High-volume data to describe the complication profile and factors associated with reoperation after minimally invasive tubular transforaminal lumbar interbody fusions (TLIFs) in the short-term (<30 days) and long-term (>30 days). Methods All tubular TLIFs (2011-2024) were retrospectively reviewed, performed by eight neurosurgeons at our single centre. Two matched controls per reoperation case were manually selected. Each control had undergone the same primary procedure within six months of the index case, at the same levels and, if possible, by the same surgeon. Variables included demographics, comorbidities, frailty indices, private/public status, workplace injury, preoperative antithrombotics, preoperative laboratory results, the symptomatic indications, surgical factors, and clinical outcomes. Univariate logistic regression identified candidate variables for multivariate analysis. Results From 756 patients, there was a 6.6% reoperation rate (n=50), with mean follow-up of 1.5 (±1.7) years. Short-term reoperation was predominantly for cage migration and multivariate analysis revealed no independent predictors. Long-term reoperation was mainly for cage migration and was associated with private-funding, WorkCover status, osteoporosis/osteopenia, and previous lumbar surgery. Combined timeframe reoperations were associated with WorkCover status, osteoporosis/osteopenia, diabetes, and previous lumbar surgery. Patients who had reoperations fared worse than their matched controls. Additionally, a worse patient outcome was associated with diabetes, a higher Modified Charlson Comorbidity Index, and previous lumbar surgery. Conclusion This retrospective case-control series reports our complication profile and factors associated with reoperation and poor patient outcomes after tubular TLIFs. Reoperation was associated with osteoporosis/osteopenia, diabetes, private-funding, WorkCover status, and previous lumbar surgery at another spinal level.
Aaron Lerch, A. Chau, Silvia Garcia Martin et al.· Global Spine Journal· 2 citations