P49. Treatment preferences for patients with metastatic spine disease with indeterminate spinal instability neoplastic scores (SINS 7-12)

Abstract

BACKGROUND CONTEXT As the survival of cancer patients increases, so has the incidence of metastatic spine disease (MSD). While surgical stabilization has demonstrated improved outcomes for some patients, there is also increased perioperative morbidity. The Spine Instability Neoplastic Score (SINS) assigns values to clinical and radiographic findings, providing recommendations for surgical stabilization. Scores 12 are best treated with surgical stabilization. Unfortunately, there are no clear recommendations for patients with indeterminate instability (SINS of 7-12). The purpose of this exploratory study is to examine treatment preferences among surgeons and radiation oncologists involved in the care of patients with MSD of indeterminate instability. PURPOSE To better understand decision-making principles in the treatment of MSD patients with indeterminate SINS. STUDY DESIGN/SETTING Multi-institutional survey study. PATIENT SAMPLE No actual patients were reviewed for this study, only representative clinical vignettes. OUTCOME MEASURES Survey participant results regarding treatment decision-making in MSD patients with indeterminate SINS. METHODS Spine surgeons and radiation oncologists from five academic, tertiary care institutions were sent an online survey using a secure REDcap database. Participants were asked about their practice characteristics and presented seven cases, including clinical vignettes and relevant imaging studies. They were asked to answer questions regarding treatment recommendations, as well as the hierarchy of factors influencing these recommendations. Five cases highlighted patients with indeterminate SINS and no neurologic deficits, while two additional cases presented patients with a SINS >12 and a SINS RESULTS Seventeen physicians from 5 institutions completed the survey, including 10 orthopaedic surgeons, 5 neurosurgeons, and 2 radiation oncologists. A total of 64.7% of participants have practiced for >10 years and 76.5% treat >10 MSD patients yearly. Eighty-five responses for 5 indeterminate cases were recorded. Surgical stabilization was recommended 43.5% of the time. Dividing indeterminate cases into low (SINS 7-9) vs high (SINS 10-12) categories, there was a trend toward surgical intervention in the high SINS cases (49.0% vs 35.3%). Pain control was the most common indication for surgical intervention (67.6% of responses), while the mechanical nature of pain (32.4%) and degree of epidural spinal cord compression (27.0%) were the most commonly cited anatomic factors for surgical stabilization. Primary cancer type more commonly influenced nonsurgical management (31.3%), which most often consisted of radiation therapy (77.0%). Radiation was more commonly selected in patients presenting with radiosensitive tumors (94.1%) vs. more radioresistant tumors (60.8%). There was an increase in surgical stabilization of radioresistant tumors compared to radiosensitive tumors (49.0% vs 35.3%). CONCLUSIONS As our survey responses demonstrate, there is uncertainty in the surgical decision-making for patients with indeterminate SINS, even among experienced, high-volume physicians. Although pain control was identified as the most common patient factor in determining treatment, surgical stabilization was more often performed when pain was mechanical, relating to patient movement and function. However, physicians were more likely to recommend non-surgical treatment, most commonly radiation, when patients had radiosensitive tumors, regardless of their SINS. Based on survey responses, MSD patients with indeterminate SINS of 10-12, presenting with mechanical pain and radioresistant tumors, are more likely to have surgical stabilization recommended. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.