The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis

Sang-Min Park; Hyoungmin Kim; Jae Hong Ha; Suk Joong Lee; Ho-Joong Kim; Jin S. Yeom; Choon-Ki Lee; Bong-Soon Chang

doi:10.4184/jkss.2018.25.2.60

Journal List > J Korean Soc Spine Surg > v.25(2) > 1098157

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Park, Kim, Ha, Lee, Kim, Yeom, Lee, and Chang: The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis

Original Article

Journal of Korean Spine Surg 2018;25(2):60-68.

Published online: 30 June 2018

DOI: https://doi.org/10.4184/jkss.2018.25.2.60

The Spinal Instability Neoplastic Score (SINS) as a Surgical Decision-Making Tool for the Treatment of Spine Metastasis

Sang-Min Park, M.D.^∗, Hyoungmin Kim, M.D., Jae Hong Ha, M.D., Suk Joong Lee, M.D.^†, Ho-Joong Kim, M.D.^∗, Jin S. Yeom, M.D.^∗, Choon-Ki Lee, M.D., Bong-Soon Chang, M.D.

Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea

^∗Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam, Republic of Korea

^†Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea

Corresponding author: Bong-Soon Chang, M.D. ORCID ID: Sang-Min Park: https://orcid.org/0000-0001-6171-3256 Hyoungmin Kim: https://orcid.org/0000-0002-4500-9653 Jae Hong Ha: https://orcid.org/0000-0002-7696-1743 Suk Joong Lee: https://orcid.org/0000-0002-6769-6474 Ho-Joong Kim: https://orcid.org/0000-0002-8205-4648 Jin S. Yeom: https://orcid.org/0000-0002-8241-5335 Choon-Ki Lee: https://orcid.org/0000-0001-7787-2972 Bong-Soon Chang: https://orcid.org/0000-0002-8992-2559 Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea TEL: +82-2-2072-3864, FAX: +82-2-764-2718 E-mail: bschang@snu.ac.kr

Received 1 May 20189 May 2018 Accepted 11 June 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

Retrospective cohort study.

Objectives

To investigate the potential clinical use of the spinal instability neoplastic score (SINS) for determining the surgical strategy, especially regarding the need for anterior support.

Summary of Literature Review

The SINS seems to enable an improved qualitative and quantitative assessment of spinal instability in patients with spinal metastasis.

Materials and Methods

We retrospectively reviewed 69 consecutive patients who underwent surgical treatment for spinal metastasis. We assessed the patients’ preoperative status with respect to each component of the SINS. Multiple logistic regression was performed to calculate odds ratios (ORs) representing the associations among SINS, age, Eastern Cooperative Oncology Group performance status, modified Tokuhashi score, as well as the preoperative Nurick grade variables and reconstruction of the anterior spinal column.

Results

Among the 6 items in the SINS, those indicating the degree of collapse and alignment had significantly higher scores in those who underwent corpectomy and anterior support (p<0.001). Multiple logistic regression revealed that the total SINS was the only factor significantly associated with predicting whether anterior support should be performed (adjusted OR=1.595). Receiver operating characteristic (ROC) curve analysis suggested that a cut-off value of 10 points on the SINS scale could be used to decide whether anterior support following corpectomy should be performed (AUC=0.706).

Conclusions

The SINS, insofar as it assesses the degree of collapse and alignment, is a potentially useful tool for determining the surgical strategy in patients with spinal metastasis, especially for deciding upon the necessity of additional anterior support procedures.

Keywords: Anterior support procedure, Spinal Instability Neoplastic Score, spinal metastasis, spinal stability

REFERENCES

1. White AP, Kwon BK, Lindskog DM, et al. Metastatic disease of the spine. J Am Acad Orthop Sur. 2006 Oct; 14(11):587–98.

2. White AA 3rd, Panjabi MM, Posner I, et al. Spinal stability: evaluation and treatment. Instr Course Lect. 1981; 30:457–83.

3. Weber MH, Burch S, Buckley J, et al. Instability and impending instability of the thoracolumbar spine in patients with spinal metastases: a systematic review. Int J Oncol. 2011 Jan; 38(1):5–12. DOI: 10.3892/ijo_00000818.

4. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010 Oct 15; 35(22):E1221–9. DOI: 10.1097/BRS.0b013e3181e16ae2.

5. Fisher CG, Versteeg AL, Schouten R, et al. Reliability of the spinal instability neoplastic scale among radiologists: an assessment of instability secondary to spinal metastases. AJR Am J Roentgenol. 2014 Oct; 203(4):869–74. DOI: 10.2214/AJR.13.12269.

6. Fourney DR, Frangou EM, Ryken TC, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol. 2011 Aug 1; 29(22):3072–7. DOI: 10.1200/JCO.2010.34.3897.

7. Findlay GF. The role of vertebral body collapse in the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry. 1987 Feb; 50(2):151–4. DOI: 10.1136/jnnp.50.2.151.

8. Roila F, Lupattelli M, Sassi M, et al. Intra and interobserver variability in cancer patients’ performance status assessed according to Karnofsky and ECOG scales. Ann Oncol. 1991 Jun; 2(6):437–9. DOI: DOI:10.1093/oxfordjournals.an-nonc.a057981.

9. Tokuhashi Y, Ajiro Y, Umezawa N. Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis. Spine (Phila Pa 1976). 2009 Jan 1; 34(1):69–73. DOI: 10.1097/BRS.0b013e3181913f19.

10. Revanappa KK, Rajshekhar V. Comparison of Nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy. Eur Spine J. 2011 Sep; 20(9):154551. DOI: DOI:10.1007/s00586-011-1773-y.

11. Zweig MH, Campbell G. Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem. 1993 Apr; 39(4):561–77.

12. Keeney S, Hasson F, McKenna HP. A critical review of the Delphi technique as a research methodology for nursing. Int J Nurs Stud. 2001 Apr; 38(2):195–200. DOI: DOI:10.1016/s0020-7489 (00)00044-4.

13. Huisman M, van der Velden JM, van Vulpen M, et al. Spinal instability as defined by the spinal instability neoplastic score is associated with radiotherapy failure in metastatic spinal disease. Spine J. 2014 Dec 1; 14(12):2835–40. DOI: DOI:10.1016/j.spinee.2014.03.043.

14. Fisher CG, Schouten R, Versteeg AL, et al. Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases. Radiat Oncol. 2014 Mar 4; 9:69. DOI: 10.1186/1748-717X-9-69.

15. Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. 1989. Clin Orthop Relat Res. 2003 Oct; 415(Suppl):S4–13. DOI: DOI:10.1097/01.blo.0000093045.56370.dd.

16. Mac Niocaill RF, Quinlan JF, Stapleton RD, et al. Inter-and intra-observer variability associated with the use of the Mirels'scoring system for metastatic bone lesions. Int Orthop. 2011 Jan; 35(1):83–6. DOI: DOI:0.1007/s00264-009-0941-8.

17. Evans AR, Bottros J, Grant W, et al. Mirels’ rating for humerus lesions is both reproducible and valid. Clin Orthop Relat Res. 2008 Jun; 466(6):1279–84. DOI: DOI:10.1007/s11999-008-0200-0.

18. Ivanishvili Z, Fourney DR. Incorporating the Spine Instability Neoplastic Score into a Treatment Strategy for Spinal Metastasis: LMNOP. Global Spine J. 2014 Jun; 4(2):12936. DOI: DOI:10.1055/s-0034-1375560.

19. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20; 366(9486):643–8. DOI: 10.1016/S0140-6736 (05)66954-1.

Fig. 1.

Receiver operating characteristic (ROC) curve analysis. Spinal instability neoplastic score (SINS) and the need for vertebral column reconstruction by anterior support.

Table 1.

The SINS classification according to Fisher et al.⁴⁾

	Score
Location
Junctional (occiput-C2, C7-T2, T11-L1, L5-S1)	3
Mobile spine (C3-C6, L2-L4)	2
Semirigid (T3-T10)	1
Rigid (S2-S5)	0
Pain^∗
Yes	3
Occasional pain but not mechanical	1
Pain-free lesion	0
Bone lesion
Lytic	2
Mixed (lytic/blastic)	1
Blastic	0
Radiographic spinal alignment
Subluxation/translation present	4
De novo deformity (kyphosis/scoliosis)	2
Normal alignment	0
Vertebral body collapse
> 50% collapse	3
< 50% collapse	2
No collapse with > 50% body involved	1
None of the above	0
Posterolateral involvement of spinal elements†
Bilateral	3
Unilateral	1
None of the above	0

^∗ Pain improvement with recumbency and/or pain with movement/loadin of spine.

^† Facet, pedicle, or costovertebral joint fracture or replacement with tumo

Table 2.

Basic clinical characteristics of patients with and without anterior support

Characteristics	Total (n=69)	Without anterior support (n=21)	With anterior support (n=48)	p-value^∗
Age (yr)	54.7±13.8	53.5±14.2	55.2±13.8	0.653
Sex (n)				0.493
Male	43	16	27
Female	26	7	19
Body weight (kg)	62.2±8.5	64.3±7.3	61.3±8.9	0.201
BMI (kg/m²)	23.3±2.9	23.4±3.0	23.2±2.9	0.792
Primary tumors (n)				0.346
Hepatocellular carcinoma	15	6	9
Urogenital	13	1	10
Lung	10	2	8
Sarcomas	8	3	5
Colorectal cancer	5	1	4
Thyroid cancer	5	1	4
Hematologic malignancy	7	4	3
Breast cancer	2	1	1
Pancreas	1	1	0
Unknown origin metastasis	3	1	2
Spinal Instability Neoplastic Score	10.20±2.4	8.95±1.5	10.75±2.5	0.039
Pain	3.00±0.0	3.00±0.0	3.00±0.0	1.000
Location	1.89±0.8	1.86±0.9	1.90±0.9	0.746
Bone lesion quality	1.55±1.6	1.33±0.8	1.65±0.5	0.317
Collapse	1.55±1.0	0.76±0.7	1.90±0.9	<0.001
Alignment	0.77±1.0	0.10±0.4	1.06±1.0	<0.001
Posterolateral involvement	1.48±1.2	1.95±1.1	1.27±1.2	0.099
ECOG performance status (n)				0.627
Grade 0	24	8	16
Grade 1	22	6	16
Grade 2	7	3	4
Grade 3	11	4	7
Grade 4	5	0	5
Modified Tokuhashi score (n)				0.778
0-8 points	26	10	16
9-11 points	25	4	21
12-15 points	18	7	11
Survival after spinal surgery (days)	653	603	675	0.408
Preoperative Nurick grade				0.294
Grade 0	24	6	18
Grade 1	18	5	13
Grade 2	5	1	4
Grade 3	5	2	3
Grade 4	2	1	1
Grade 5	15	6	9
Postoperative Nurick grade	1.59	1.8	1.5	0.690
Grade 0	25	7	18
Grade 1	20	5	15
Grade 2	8	3	5
Grade 3	1	1	0
Grade 4	4	1	3
Grade 5	11	4	7
Neurologic recovery rate (%)	30.8	43.9	25.0	0.928
Grade of Excision of Body (n)				<0.001
0: no corpectomy	15	15	0
1: corpectomy<50%	7	7	0
2: corpectomy>50%	38	0	38
3: spondylectomy	9	0	9

Numeric parameters are expressed as mean±standard deviation in parentheses.

Categorical parameters are expressed as counts.

BMI: body mass index, ECOG: Eastern Cooperative Oncology Group

^∗ p-value as two-tailed probability from comparison of groups with and without anterior support by t-test for variables with normal distribution (age, body weight, BMI); primary tumor & pre- & post-operative neurologic status (Nurick grade) by Chi-square test; other variables by Mann-Whitney test

Table 3.

Association between spinal instability neoplastic score (SINS) and reconstruction with anterior support using multiple logistic regression

	Unadjusted OR (95% CI)	p-value	Adjusted OR^∗ (95% CI)	p-value
Without anterior support	1.0	0.004	1.0	0.004
With anterior support	1.527 (1.144 - 2.039)		1.677 (1.179 - 2.387)

OR: Odds radio, 95% CI: 95% confidence interval

^∗ Adjusted by age, body mass index, Eastern Cooperative Oncology Group performance score, modified Tokuhashi score, preoperative Nurick grade.

TOOLS

Similar articles