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The SPine response assessment In Neuro-Oncology (SPINO) group is a committee of the Response Assessment in Neuro-Oncology working group and comprises a panel of international experts in spine stereotactic body radiotherapy (SBRT). Here, we present the group's first report on the challenges in standardising imaging-based assessment of local control and pain for spinal metastases. We review current imaging modalities used in SBRT treatment planning and tumour assessment and review the criteria for pain and local control in registered clinical trials specific to spine SBRT. We summarise the results of an international survey of the panel to establish the range of current practices in assessing tumour response to spine SBRT. The ultimate goal of the SPINO group is to report consensus criteria for tumour imaging, clinical assessment, and symptom-based response criteria to help standardise future clinical trials.

Abstract BACKGROUND Over the last 2 decades, advances in systemic therapy have increased the expected overall survival for patients with cancer. It is unclear whether the same survival benefit has been conferred to patients requiring surgery for metastatic spinal disease. OBJECTIVE To examine trends in postoperative survival over a 20-yr period for patients surgically treated for spinal metastatic disease. METHODS Data were obtained for 1515 patients who underwent surgery for metastatic epidural spinal cord compression or tumor-related mechanical instability. Postoperative overall survival was calculated for all included patients using Kaplan-Meier methodology from date of surgery until death or last follow-up for those who were censored. Trends were analyzed using Cox proportional hazards modeling. RESULTS Patients with renal, breast, lung, and colon cancers experienced a statistically significant improvement in survival over time based on the year of surgery (40%-100% improvement over the study period), whereas the overall survival trend for the entire cohort did not reach statistical significance (P = .12, median survival 0.71 yr, 95% CI 0.63-0.78). Patients presenting with synchronous metastatic disease had better survival compared to those presenting with metachronous disease (median overall survival: 0.94 vs 0.63 yr, respectively; log-rank P-value = .00001). CONCLUSION The postoperative survival among patients with spinal metastases has improved over the past 20 yr, particularly in patients with kidney, breast, lung, and colon tumors metastatic to the spine. The observed survival improvement emphasizes the need for long-term outcome consideration in treatment decisions for patients undergoing surgery for spinal metastatic tumors.

Case studies are a cornerstone of medical education and have been shown to be effective teaching tools. When teaching is entertaining, learning is enhanced and, therefore, strange and unusual cases present the opportunity to illustrate issues of disorder and illness in an engaging manner. The author illustrates this concept by presenting the life and character of Joshua Norton, who declared himself Emperor of the USA in 1859 and “reigned” until his death in 1880. Although grandiose claims are not rare among patients, Norton is unlike most self-proclaimed royalty in that his community embraced him and joined in with his fantasy. No psychiatrist or psychologist has ever opined on the matter of whether or not Norton’s claims stemmed from mental disorder, and the author therefore presents Emperor Norton as a unique case in psychiatric history to explore first what diagnosis best explains his story and, second, whether he merits a diagnosis at all.

Abstract BACKGROUND: Tumor-associated sacral insufficiency fractures (SIF) present a significant clinical challenge. As survival increases for many malignancies, sacral fractures associated with metastases, sacral or extended pelvic radiation, and paraneoplastic osteoporosis are increasingly common and yet remain difficult to treat in the setting of the potentially significant morbidity of open sacral surgery. OBJECTIVE: To describe our prospective experience with sacroplasty for tumor-associated lesions, including the largest series to date of radiation-induced SIF. METHODS: Twenty-five patients with symptomatic SIF underwent 31 percutaneous fluoroscopy-guided sacroplasties with a median 5.8 mL of polymethyl methacrylate or a ceramic-resin composite under fluoroscopic guidance and with concurrent biopsy acquisition. Eighteen patients had fractures related to previous sacral or pelvic radiation; 4 had viable lytic lesions; and 2 had oncology-related osteoporosis. Postoperative pain reduction, procedural morbidity, and functional outcomes were recorded. RESULTS: Twenty of 25 patients (80%) had reduction in their visual analog pain score at a median follow-up of 6.5 months; no patients worsened. The mean visual analog scale score decreased from 8.8 to 4.7 postprocedurally (P < .001), with significant reductions regardless of the underlying pathology (P < .001 to P < .05). Six of 13 patients with pretreatment ambulatory impairment required fewer ambulatory aids and 3 were newly ambulatory. Extravertebral cement migration was noted in 18 procedures; however, no instance was clinically relevant. Six repeat or contralateral procedures were performed. No morbidity was encountered. CONCLUSION: Sacroplasty is a safe and effective option for the palliation of sacral fractures in the oncologic population.

Introduction. Tumors invading the sacrum and/or ilium often represent incurable metastatic disease, and treatment is targeted toward palliation of symptoms and control of pain. As systemic opioid therapy is frequently inadequate and limited by side effects, a variety of interventional techniques are available to better optimize analgesia. Using six patients as a paradigm for interventional approaches to pain relief, we present a therapeutic algorithm for treating sacroiliac tumor–related pain in the oncologic population. Methods. We describe the use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, and implantable neuraxial drug delivery devices to treat malignant sacroiliac pain in six patients. Pre- and postprocedure numerical rating scale (NRS) pain scores, duration of pain relief, and postprocedure pain medication requirements were studied for each patient. Results. Each patient had marked improvement in their pain based on an average postprocedure NRS difference of six points. The average duration of pain relief was eight months. In all cases, opioid requirements decreased after the intervention. Discussion. Depending on tumor location, burden of disease, and patient preference, patients suffering from metastatic disease to the sacrum may find benefit from use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, dorsal column stimulator leads, and/or implantable neuraxial drug delivery devices. We provide a paradigm for treatment in this patient population. Key Words. Sacroiliac Joint Syndrome; Cancer Pain; Sacroiliac Joint Injection; Radiofrequency Denervation; Lateral Branch Block; Lateral Branch Neurotomy; Sacroplasty; Intrathecal Drug Delivery; Spinal Cord Stimulation; Sacroiliitis; Sacral Tumors

Abstract INTRODUCTION Targeted therapies have improved overall survival in multiple cancer types. Hence, associated long term complications must be considered with current treatment paradigms. The objective of this study is to evaluate outcomes of long-term cancer survivors surgically treated for symptomatic spinal metastases. METHODS Retrospective chart review of patients who were surgically treated at a tertiary cancer center from January 2010 to December 2015 and survived at least 24 mo after treatment. Patients without clinical or radiological follow-up of at least 24 mo were excluded. Collected data included patient demographics, tumor histology, type and extent of spinal intervention, radiation data including treatment dose and field, long-term sequelae including local tumor control, reirradiation, reoperation, or postoperative kyphoplasty at previously treated level. RESULTS Seventy-three patients were included in the final analysis, of which 36 were males and 37 females with a mean age of 60.9. The most common histologies were renal cell (19.1%), breast (17.8%), multiple myeloma (16.4%), thyroid (12.3%), and nonsmall cell lung carcinoma (8.2%). Open surgery was performed in 56 patients (76.7%) and minimal access surgery in 17 (23.2%). Postoperative radiation was delivered in 43 (58.9%) cases while 21(28.7%) received preoperative radiation and were subsequently operated for tumor progression or spinal instability and 9 (12.3%) patients did not receive adjuvant radiation. Stereotactic body radiation therapy was used in 42 (65%) radiation treatments. Mean clinical and radiographic follow-up was 3.7 yr at long-term follow-up; 80% of patients had a Karnofsky performance status of 80 or higher (ie, functionally independent). Re-operations were performed in 16 patients (22%) including 8 for hardware revision, 4 tumor progressions, 3 wound complications, and 1 postoperative blood clot. Postoperatively, kyphoplasty for progressive fractures at the treated level was performed in 3 cases (4%). Re-irradiation was performed in 13 cases (17.8%) with a median time to re-irradiation of 1.8 yr. CONCLUSION Durable tumor control can be achieved in long-term cancer survivors surgically treated for symptomatic spinal metastases with a limited complication profile. Long-term sequelae include local tumor recurrence/progression, marginal radiation failures, early or late hardware failures, and progressive spinal instability or deformity.

Purpose: Dynamic contrast-enhanced magnetic resonance imaging offers noninvasive characterization of the vascular microenvironment and hemodynamics. Stereotactic radiosurgery, or stereotactic body radiation therapy, engages a vascular component of the tumor response which may be detectable using dynamic contrast-enhanced magnetic resonance imaging. The purpose of this study is to examine whether dynamic contrast-enhanced magnetic resonance imaging can be used to predict local tumor recurrence in patients with spinal bone metastases who undergo high-dose radiotherapy with stereotactic radiosurgery. Materials and Methods: We conducted a study of 30 patients with spinal metastases who underwent dynamic contrast-enhanced magnetic resonance imaging before and after radiotherapy. Twenty patients received single-fraction stereotactic radiosurgery (24 Gy), while 10 received hypofractionated stereotactic radiosurgery (3-5 fractions, 27-30 Gy total). Kaplan-Meier analysis was used to estimate the actuarial local recurrence rates. Two perfusion parameters (Ktrans: permeability and Vp: plasma volume) were measured for each metastasis. Percentage change in parameter values from pre- to posttreatment was calculated and compared. Results: At 20-month median follow-up, 5 of the 30 patients had pathological evidence of local recurrence. One- and 3-year actuarial local recurrence rates were 24% and 44% for the hypofractionated stereotactic radiosurgery cohort versus 5% and 16% for the single-fraction stereotactic radiosurgery cohort (P = .20). The average change in Vp and Ktrans for patients without local recurrence versus those with local recurrence was −76% and −66% versus +28% and −14% (P < .01 for both). With a cutoff point of −20%, Vp had a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 98%, 91%, and 100%, respectively, for the detection of local recurrence following high-dose radiotherapy. Using this definition, dynamic contrast-enhanced magnetic resonance imaging identified local recurrence up to 18 months (mean [standard deviation], 6.6 [6.8] months) earlier than standard magnetic resonance imaging. Conclusions: We demonstrated that changes in perfusion parameters, particularly Vp, after high-dose radiotherapy to spinal bone metastases were predictive of local tumor recurrence. These changes predicted local recurrence on average >6 months earlier than standard imaging did.

Abstract BACKGROUND Cancer patients experience pathological fractures and the typical poor bone quality frequently complicates stabilization. Methods for overcoming screw failure include utilization of fenestrated screws that permit the injection of bone cement into the vertebral body to augment fixation. OBJECTIVE To evaluate the safety and efficacy of cement augmentation via fenestrated screws. METHODS A retrospective chart review of patients with neoplastic spinal instability who underwent percutaneous instrumented stabilization with cement augmentation using fenestrated pedicle screws. Patient demographic and treatment data and intraoperative and postoperative complications were evaluated by chart review and radiographic evaluation. Prospectively collected patient reported outcomes (PRO) were evaluated at short (2- <6 mo) and long term (6-12 mo). RESULTS Cement augmentation was performed in 216 fenestrated pedicle screws in 53 patients. Three patients required reoperation. One patient had an asymptomatic screw fracture at 6 mo postoperatively that did not require intervention. No cases of lucency around the pedicle screws, rod fractures, or cement extravasation into the spinal canal were observed. Eight cases of asymptomatic, radiographically-detected venous extravasation were found. Systemic complications included a pulmonary cement embolism, a lower extremity deep vein thrombosis, and a postoperative mortality secondary to pulmonary failure from widespread metastatic pulmonary infiltration. Significant improvement in PRO measures was found in short- and long-term analysis. CONCLUSION Cement augmentation of pedicle screws is an effective method to enhance the durability of spinal constructs in the cancer population. Risks include cement extravasation into draining blood vessels, but risk of clinically significant extravasation appears to be exceedingly low.