 SPINE

The Oswestry Risk Index

AN AID IN THE TREATMENT OF METASTATIC DISEASE OF THE
SPINE

B. Balain, The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make
A. Jaiswal, difficult decisions in the management of patients presenting with spinal metastases. A
J. M. Trivedi, prospective cohort study of 199 consecutive patients presenting with spinal metastases,
S. M. Eisenstein, treated with either surgery and/or radiotherapy, was used to compare the three systems.
J. H. Kuiper, Cox regression, Nagelkerke’s R2 and Harrell’s concordance were used to compare the
D. C. Jaffray systems and find their best predictive items. The three systems were equally good in terms
of overall prognostic performance. Their most predictive items were used to develop the
From The Centre for Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient
Spinal Studies, of determination than any of these three scores. A bootstrap procedure was used to
Robert Jones & internally validate this score and determine its prediction optimism.
Agnes Hunt The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and
Orthopaedic and general condition (GC): OSRI = PTP + (2 – GC).
District Hospital This simple score can predict life expectancy accurately in patients presenting with spinal
NHS Trust, metastases. It will be helpful in making difficult clinical decisions without the delay of
Oswestry, United extensive investigations.
Kingdom
Cite this article: Bone Joint J 2013;95-B:210–16.

The decision-making process in the treatment derived for surgically treated patients, the
of patients with metastatic disease of the spine modified Bauer score,4 could distinguish
is seldom easy. The two main concerns in a significantly between patients with good, mod-
patient who might become paralysed are the erate or poor survival prospects.8,9 Three fur-
 B. Balain, MS, FRCS, FRCS(Tr
patient’s life expectancy when they present and ther studies assessed the validity of the revised
& Orth), Consultant Spinal the potential for added morbidity from treat- Tokuhashi score.10-12 Two found it could pre-
Surgeon
 A. Jaiswal, MS, MRCS,
ment. Various scoring systems have been pro- dict survival,10,11 but the third found it only
Speciality Trainee posed to predict life expectancy and help poorly predicted survival in a group of Euro-
 J. M. Trivedi, FRCS, MCh,
FRCS(Tr & Orth), Consultant
decision making in these patients. Some are pean patients.12 The two original studies and
Spinal Surgeon applicable to all patients1,2 and others to spe- the five evaluative studies had a predominance
 S. M. Eisenstein, FRCS,
Consultant Spinal Surgeon
cific subgroups, for example those treated sur- of surgically treated patients.
 D. C. Jaffray, FRCS, gically,3,4 conservatively,5 or those with Various researchers have suggested modifica-
Consultant Spinal Surgeon
Robert Jones & Agnes Hunt
epidural metastases.6 A scoring system valid tions to these scores,13,14 or reported on specific
Orthopaedic and District for all patients, rather than a specific subset, conditions where they do not help.15,16 Internal
Hospital NHS Trust, Oswestry,
Shropshire SY10 7AG, UK.
would be most useful for deciding between and external validation can address such prob-
available treatments. It is therefore not surpris- lems, ideally using a measure of overall perfor-
 J. H. Kuiper, PhD, Lecturer
Keele University, Institute for ing that the two scoring systems applicable to mance of the scoring system against individual
Science and Technology, all patients, the revised Tokuhashi1 and the elements that make up that system.7 To our
Staffordshire ST5 5BG, UK.
Tomita2 scores, are widely cited and used. knowledge, such methods have not been used
Correspondence should be sent
to Mr A. Jaiswal; e-mail:
The items that make up these scores and so far. In addition, the scoring systems could be
anujdr@gmail.com their weightings were obtained from single improved by combining their best elements in a
©2013 The British Editorial
cohort studies, which means that they may not manner similar to the combined staging system
Society of Bone & Joint perform as well in a new group of patients.7 for trophoblastic disease.17
Surgery
doi:10.1302/0301-620X.95B2.
Five studies have validated the revised The aims of the current study were: 1) to
29323 $2.00 Tokuhashi and the Tomita scoring systems in a compare the variation and discriminative abil-
Bone Joint J
mixed group of patients with spinal metasta- ity of three prognostic scoring systems for
2013;95-B:210–16. ses.8-12 Two studies compared seven scoring patients with spinal metastases, the revised
Received 5 February 2012;
Accepted after revision 5
systems, including the revised Tokuhashi and Tokuhashi, the Tomita and the modified Bauer
December 2012 Tomita systems, but found that only a score score; and 2) to develop an improved,

210 THE BONE & JOINT JOURNAL

 THE OSWESTRY RISK INDEX
Table I. Overview of patient characteristics
Characteristic
Patients (n) 199
Female (n, %) 81 (41)
Male (n, %) 118 (59)
Mean (SD) age (yrs) 61.6 (12.5)
Primary site (n, %)
Breast 33 (17)
Prostate 31 (16)
Bronchus 20 (10)
Kidney 18 (9)
Myeloma 18 (9)
Adenocarcinoma (unknown origin) 13 (7)
Lymphoma 12 (6)
Others (< 10 each) 54 (27)
Treatment (n, %)
Surgical 104 (52)
Conservative 95 (48)
internally validated scoring system by combining the most
predictive items of these scores. Although the modified
Bauer system has been derived to predict survival of surgi-
cally treated patients, we included it in this study because it
proved the most predictive in comparative studies.8,9
Patients and Methods
After obtaining ethical approval, a cohort of 199 consecu-
tive patients with spinal metastases was used for this study.
Survival of patients was evaluated in September 2010.
The clinical parameters recorded included age at presen-
tation, gender, primary tumour, staging information and
individual items used in the three scoring systems. The deci-
sions in relation to treatment were also recorded.
Patient survival was analysed using Cox regression and
age, gender, the individual items of the three scoring systems,
and their total scores as independent variables. Two overall
measures of performance were used to compare the various
parameters. The first was a generalisation of the coefficient
of determination (Nagelkerke’s R2), a measure of the
explained variation in survival times.7,18 It captures aspects
of calibration such as how well predicted risk agrees with
actual risk, and discrimination such as how well the pre-
dicted ranking of patients in terms of risk agrees with their
actual ranking.19 The second was the concordance ‘c’, a
measure of discriminative ability of the individual predictive
parameter.7,20 The concordance estimates the probability
that, of two randomly chosen patients, the patient with the
higher prognostic score will outlive the patient with the
lower score, and is a generalisation of the area under the
receiver operating characteristic curve (AUC).7 Since calibra-
tion and discrimination are both important in prognostic
risk scores,21 we mainly used Nagelkerke’s R2 to compare
the scoring systems. Confidence limits for these two meas-
ures were determined using 150 bootstrap replications.
By combining the best-performing individual items as
judged from the Cox regression, a new risk index was
VOL. 95-B, No. 2, FEBRUARY 2013
211
formulated. Robustness of the new index was investigated
and its parameters optimised using leave-one-out cross val-
idation and a shrinkage procedure.22 The new index was
then internally validated by a bootstrapping method23
using 150 bootstrap replications.
All statistical analyses were performed with R version
2.13.0 (R Foundation for Statistical Computing; University
of Vienna, Vienna, Austria) using the packages Survival,
Penalized, rms and boot (all R software). A p-value of
< 0.05 was assumed to denote statistical significance.
Results
Of the 199 patients, 118 were male and 81 female, with a
mean age of 62 years (23 to 86). The most common site of
the primary tumour was the breast (n = 33) and over half
the patients were treated surgically (Table I). At the time of
evaluation, only 18 patients were still alive, with a maxi-
mum survival time of 14 years. The median survival time
for the whole group of patients was six months.
Each of the three scoring systems was significantly asso-
ciated with survival time (Table II, Models 1 to 3). All sys-
tems explained approximately the same amount of
variation in survival times (Nagelkerke’s R2 = 0.15 to 0.17),
and were equally good at comparing survival between
patients (c = 0.64 to 0.67) (Table II).
We then analysed each individual scoring item in a uni-
variable Cox regression. The Tomita and modified Bauer’s
scoring items for primary tumour were highly associated
with survival (Nagelkerke’s R2 = 0.18 and 0.19, respec-
tively). The scores for general condition and visceral metas-
tases were also highly associated with survival. Age and
gender were not associated with survival (Table III). When
using gender, age and all twelve dissimilar items of the three
scoring systems as independent variables in a multivariable
Cox regression analysis, we found five parameters signifi-
cantly associated with survival, namely Tomita’s primary
tumour score, the general condition score, the modified
Bauer’s score for absence of lung cancer, revised
Tokuhashi’s extra-spinal bone metastasis score, and any of
the major internal organ metastasis scores (Table II,
Model 4). These five parameters explained a larger propor-
tion of the variance in survival times than any of the three
original scores (Nagelkerke’s R2 = 0.31; Table II). The com-
bination of these five parameters represents the best-fit full
model for predicting survival.
Since the score components for metastasis to viscera/
internal organs or the bony skeleton had smaller individual
coefficients of determination (Nagelkerke’s R2 ? 0.05) than
the other three (Nagelkerke’s R2 > 0.05), we also fitted a
model using only these last three predictors. A model with
these predictors would not rely on extra investigations to
predict survival. This model, based only on Tomita’s pri-
mary tumour score, the general condition score and the
absence of lung cancer in the modified Bauer score,
explained 27% of the variation in survival times
(Nagelkerke’s R2 = 0·27; Table II, Model 5). Shrinking
212 B. BALAIN, A. JAISWAL, J. M. TRIVEDI, S. M. EISENSTEIN, J. H. KUIPER, D. C. JAFFRAY

Table II. Cox regression analysis of the three existing prognostic models (Models 1 to 3) and three new models that are based on items from the
three existing models (Models 4 to 6) (CI, confidence interval)

Model* Coefficient Hazard ratio (95% CI) p-value Nagelkerke’s R2 (95% CI) c (95% CI)
2
1. Revised Tokuhashi score 0.83 (0.79 to 0.88) < 0.0001 0.18 (0.08 to 0.26) 0.67 (0.65 to 0.73)

2. Tomita score1 1.22 (1.15 to 1.30) < 0.0001 0.17 (0.08 to 0.26) 0.65 (0.62 to 0.71)

3. Modified Bauer score4 0.63 (0.54 to 0.74) < 0.0001 0.15 (0.06 to 0.23) 0.64 (0.61 to 0.70)

4. All significant items 0.31 (0.19 to 0.39) 0.70 (0.65 to 0.74)

- Primary tumour (Tom.) 0.35 1.42 (1.24 to 1.63) < 0.0001
- General condition (Tok.) -0.32 0.73 (0.59 to 0.89) 0.002
- Extrasp. bone mets (Tok.) -0.20 0.82 (0.70 to 0.95) 0.009
- No lung cancer (Bauer) -0.69 0.50 (0.29 to 0.87) 0.01
- Major organs mets (any) -0.19 0.83 (0.71 to 0.97) 0.02

5. Primary tumour and general condition 0.27 (0.17 to 0.34) 0.68 (0.64 to 0.72)
- Primary tumour (Tom.) 0.33 1.38 (1.21 to 1.58) < 0.0001
- General condition (Tok.) -0.38 0.68 (0.56 to 0.83) 0.0002
- No lung cancer (Bauer) -0.69 0.50 (0.29 to 0.87) 0.01

6. Oswestry Spinal Metastasis Risk Index (OSRI) 1.91 (1.64 to 2.23) < 0.0001 0.28 (0.20 to 0.37) 0.67 (0.64 to 0.72)
* Tom., taken from Tomita system1; Tok., taken from revised Tokuhashi system2; Bauer, taken from Bauer system4; any, taken from any of the three
existing scoring systems; extrasp., extra-spinal; mets, metastases

Table III. Univariable analysis of individual items in the scoring systems (CI, confidence interval)

Item Hazard ratio (95% CI) p-value Nagelkerke’s R2 c

Revised Tokuhashi
General condition (KPS*) 0.63 (0.52 to 0.76) < 0.001 0.11 0.63
Primary tumour site 0.87 (0.79 to 0.96) 0.005 0.04 0.59
Major internal organ metastases 0.76 (0.65 to 0.89) < 0.001 0.05 0.58
Extra-spinal bone metastases 0.86 (0.74 to 1.00) 0.05 0.02 0.54
Spinal bone metastases 0.83 (0.71 to 0.98) 0.03 0.02 0.55
Palsy 0.76 (0.60 to 0.98) 0.03 0.02 0.58

Tomita
Primary tumour grade 1.50 (1.33 to 1.68) < 0.001 0.19 0.63
Metastases to vital organs 1.14 (1.06 to 1.24) < 0.001 0.05 0.58
Bone metastases including spine 1.32 (0.95 to 1.85) 0.10 0.01 0.53

Modified Bauer
No vital organ metastases 0.76 (0.65 to 0.89) < 0.001 0.05 0.58
No lung cancer 0.23 (0.14 to 0.38) < 0.001 0.12† 0.56‡
Primary tumour breast, kidney, lymphoma, multiple myeloma 0.49 (0.36 to 0.64) < 0.001 0.10† 0.60‡
One solitary skeletal metastasis 0.76 (0.54 to 1.06) 0.09 0.01 0.53

Others
Age 1.01 (1.00 to 1.02) 0.12 0.01 0.55
Gender (male) 1.25 (0.92 to 1.68) 0.15 0.01 0.54
* KPS, Karnofsky Performance Status
† the combined R2 for the two Bauer primary tumour items is 0.18
‡ the combined c for the two Bauer primary tumour items is 0.63

the coefficients such that they maximised the fit using
leave-one-out cross validation mainly affected the coeffi-
cient associated with the absence of lung cancer (optimised
coefficients 0.32, -0.35 and -0.43 respectively for the
three items).
Based on the coefficients of the optimised Cox model,
which were essentially equal for the three parameters, we
constructed a simplified Oswestry Spinal Metastasis Risk
Index (OSRI) ranging from one to seven by adding the three
parameters, after inverting the general condition score. The
OSRI is a simple summation of two elements: primary
tumour pathology (PTP) and general condition (GC): OSRI
= PTP + (2 – GC). The reversal of the general condition
score was needed because the Tomita score is a risk index

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 THE OSWESTRY RISK INDEX 213

Table IV. Oswestry Spinal Metastasis Risk Index (OSRI) 1.0

Score*
OSRI = 1
Characteristic Description
OSRI = 2,3
Primary tumour 0.8 OSRI = 4,5
Slow growth Breast, thyroid, prostate, myeloma, 1 OSRI = 6
haemangioma, endothelioma, non- OSRI = 7
Hodgkins lymphoma 0.6

Survival
Moderate growth Kidney, uterus, tonsils, epipharynx, 2
synovial cell sarcoma, metastatic
thymoma 0.4
Rapid growth Stomach, colon, liver, melanoma, 4
teratoma, sigmoid colon, pancreas,
rectum, unknown origin
0.2
Very rapid growth Lung 5

General condition (KPS†) 0.0

Good KPS 80% to 100% 0
Moderate KPS 50% to 70% 1 0 12 24 36 48 60
Poor KPS 10% to 40% 2 Time after operation (months)
* total score is sum of the two sub-scores. Scoring for general
condition has been reversed compared with the revised Tokuhashi Numbers at risk 0 months 12 months 24 months 36 months 48 months 60 months
scoring system to obtain an index of risk
† KPS, Karnofsky Performance Status
OSRI = 1 47 31 20 16 13 10
OSRI = 2,3 82 30 19 9 6 3
OSRI = 4,5 43 7 3 1
OSRI = 6 16
Table V. Median survival time in each risk category. The calculation OSRI = 7 11
of the Brookmeyer-Crowley 95% confidence interval (CI) was based
on log-transformed interval Fig. 1
th
Median survival time 85 centile of Survival curves for the five risk groups defined by the Oswestry Spinal
Risk index n (95% CI) (mths) survival time (mths) Metastasis Risk Index (OSRI), showing statistically significant difference
in survival between adjacent risk groups (log rank test, p < 0.03 for each
1 47 23 (12 to 36) 69 comparison).
2 or 3 82 6 (4 to 9) 30
4 or 5 43 4 (3 to 5) 12
6 16 2 (1 to 3) 6
7 11 1 (1 to 2) 2
Model 6). Median survival times ranged from 23 months
for patients with a risk index of one to one month for
patients with a risk index of seven (Table V, Fig. 1). For
whereas the revised Tokuhashi score is a prognostic index. patients with a risk index of one, 85% had died after
The absence of lung cancer in the modified Bauer score was 69 months whereas for patients with a risk index of seven,
incorporated into Tomita’s primary tumour score by add- 85% had died after two months (Table V).
ing one extra category (very rapid tumour growth) consist-
ing only of lung cancer (Table IV). When comparing survival Discussion
curves of patients with adjacent Risk Index scores using the In this prospective study of consecutive patients presenting
log-rank test, we found no significant difference in survival with spinal metastases, we found that all three prognostic
between patients with a score of two vs three, three vs four, scores investigated correlated significantly with survival
and four vs five. We therefore decided to combine the groups and were equally good at discriminating between survival
with a score of two or three and the groups with a score of times. Using the most predictive and discriminative items
four or five, leaving five risk groups (Table V). Survival times from these scores, the new OSRI is proposed.
differed significantly between adjacent risk groups (log-rank Our finding regarding statistical significance of the three
test, p < 0.03 for each comparison) (Fig. 1). The bootstrap scoring systems is in line with two earlier validation stud-
internal validation method gave an optimism in c of 0.00075 ies.8,9 Unlike our study, these two studies found a single sys-
and in Nagelkerke’s R2 of 0.001 (0.1% and 0.3% of the tem that best distinguished survival times between
original values, respectively), suggesting the OSRI would prognostic groups, in the form of the modified Bauer score.
perform similarly in a new patient group. The different conclusions are partly related to the methodol-
The OSRI correlated nearly as well with patient survival ogy used for comparison. In our study, measures of overall
as the best-fit full model (Nagelkerke’s R2 = 0.28 and 0.31 performance (Nagelkerke’s R2 and c) were used,7,18,20
respectively; Table II, Model 5 and 6). Its concordance of whereas the earlier studies checked whether a statistically
0.67 was comparable to that of the original scoring sys- significant difference in survival was found between prog-
tems, indicating that it would perform similarly in discrim- nostic groups as defined by each scoring system. The advan-
inating between patients (Table II, Model 6 vs Models 1 to tage of measures of overall performance is that they directly
3). Each point increase or decrease on this index increases summarise the important properties of calibration and dis-
or decreases the risk of dying by a factor of 1.9 (Table II, crimination in the model7,19 without being directly

VOL. 95-B, No. 2, FEBRUARY 2013

214 B. BALAIN, A. JAISWAL, J. M. TRIVEDI, S. M. EISENSTEIN, J. H. KUIPER, D. C. JAFFRAY
influenced by sample size, whereas statistical significance on
its own is considerably influenced by sample size. Another
difference may be the nature of the studies. Our study was a
prognostic study of 199 patients. One earlier study was also
prognostic but smaller (69 patients),8 making it more diffi-
cult to generalise their findings. The other comparative study
was larger (254 patients) but retrospective.9 From the
451 patients eligible for that study, almost half (197) were
excluded as a result of loss to follow-up or missing data.9 In
addition, our study has a minimal treatment bias (surgical
treatment ≈ 50%), and a more homogenous spread of data
across various types of primary tumour.
The differences between scoring systems become clear
when comparing the variation and discriminative ability of
their individual items. For each system, only one or two
items had a strong relationship to survival times
(Nagelkerke’s R2 > 0.05). The type of the primary tumour
had a strong correlation with survival times for all scores.
This is not surprising given the wide differences in survival
between various cancers,24 which is most likely to be related
to factors such as different probabilities for lethal spread of
cells from various tumours.25,26 Clear differences do, how-
ever, exist between the systems in assigning scoring values to
different tumours. As a result of these differences the associ-
ation between the type of tumour and survival varied from
Nagelkerke’s R2 = 0.04 (revised Tokuhashi) to 0.19 (Tomita).
There may be two main reasons for the different perfor-
mances of primary tumour items, namely the number of
tumour groups and the weighting of each group. The two
best performing items (Tomita and modified Bauer) distin-
guished between a small number of tumour groups and had
weightings derived from a Cox regression analysis.2,4 The
worse performing revised Tokuhashi item distinguishes six
groups,1 increasing the risk of misranking specific tumours.
Other authors have indeed pointed out that ranking of spe-
cific tumours in the revised Tokuhashi system should be
changed, especially unknown primaries, lung and breast
cancers.13-15 Moreover, it is not clear how the weightings in
the revised Tokuhashi tumour item were derived. Since
Tomita’s primary tumour item formed the main basis of the
primary tumour item in the OSRI, we retained Tomita’s
labels based on tumour growth (Table IV) even though
other factors such as the probability of lethal spread of cells
from the tumour are considered more important determi-
nants of the aggressiveness of a tumour.25,26
The second item that strongly correlated with survival
(Nagelkerke’s R2 = 0.11 is the patient’s general condition,
and is part of the revised Tokuhashi system. Earlier com-
parative studies of scoring systems for spinal metastases
found that a poorer general condition predicted better
survival.8,9 However, many other studies have found the
same positive correlation between general condition and
survival as our study.6,10,12,27,28 Tomita et al2 believed that
the general condition was reflective of the status of the vis-
ceral metastasis, although they did not investigate this
proposed link.
The visceral metastases item was nearly identical for all
scoring systems, and significantly associated with survival
in our study, albeit with a low coefficient of determination
(Nagelkerke’s R2 = 0.05). Although skeletal metastases
items differed between the systems, its association with
survival was weak for all (Nagelkerke’s R2 ≤ 0.02). The
larger importance of visceral metastases compared to
bony metastases in predicting survival in this study con-
curs with other studies.4-6,28
Clearly from the above, the similar overall ability of the
scoring systems to predict survival hides major differences in
performance between individual items within each system. It
is therefore not surprising that prediction of survival
improved after combining the most predictive items
(Nagelkerke’s R2 = 0.31 vs Nagelkerke’s R2 = 0.15 to 0.18
for the original systems). Two specific items from the revised
Tokuhashi system, the number of affected vertebrae and the
neurological condition, were not significant in multivariate
analysis, yet their importance has been stressed.1,3,29 The
most probable explanation for the disappearance of these
items on multivariate analysis is their link to better predic-
tors. Any patient with a neurological deficit is also likely to
score poorly on general condition. Likewise, the presence of
multiple spinal metastases is likely to correlate with the pres-
ence of extra-spinal bony metastases. Nevertheless, this
information is important for surgical planning.
Determining visceral and skeletal metastases is impor-
tant for staging, but requires extensive investigations that
may not be available in urgent situations. With radiographs
and mammograms, lesions smaller than two millimetres are
likely to be missed.30,31 The OSRI excluded information on
these metastases and predicted survival almost as well as
the best-fit full model (Nagelkerke’s R2 = 0.28 vs 0.31),
meaning the hardest-won information had the smallest
yield in terms of prediction of survival.
Tumour cells from metastases contribute identically to
the risk of dying as those from the site of the primary
tumour.32 Their exact contribution depends on the type of
primary tumour, and is, for instance, larger for melanoma
than for breast carcinoma.32 This explains the importance
of the site of the primary tumour in predicting survival.
Nevertheless, why does information on metastases help so
little in the prediction of survival for these patients? It is
most likely that the effect of the extra volume of tumour
represented by metastases is overwhelmed by the large dif-
ferences in survival from different types of tumour.
Although tumour load is important in predicting survival,33
it is probably less helpful in a group with a wide variety of
primary pathology, as seen in this study. In addition, all
patients in this study had spinal metastases, and precise
information on the exact size of further metastases may be
less relevant.
The survival times of patients in adjacent risk groups in
the OSRI differ significantly, making predictions clinically
relevant. Although the difference in median survival times
was small between some of the five risk groups, the time at
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 THE OSWESTRY RISK INDEX
which 85% of patients had died doubled with each drop in
category of risk. In our experience and that of others,34
knowledge of this higher quantile is useful in discussions
with patients and decisions about management. We have
refrained from using the OSRI as a basis for specific
surgical recommendations, because treatment for each
patient is highly individualised with due consideration to
spinal stability, pain, neurological deficit and expected local
tumour control. Medical co-morbidities, personal, and
social circumstances of the patients all contribute to the
decision making process.
Our study includes 40 patients (20%) with myeloma or
lymphoma. These patients have been excluded in two of the
scoring systems1,2 but included in the modified Bauer
system4 and in studies comparing the scores.8,9 Although
the results presented in this study included these patients,
the statistical analysis was also done after excluding them
(data not shown). No noticeable difference in results was
found, in line with the initial studies.8,9
A strength of the OSRI is its use of existing knowledge
from other scoring systems.7 This also represents a weak-
ness, as potential improvements have been omitted. For
instance, we could have devised our own primary tumour
item that would outperform Tomita’s item in our patients.
However, doing so would increase the risk of poor generali-
sation to new situations. Another way to improve the system
would have been to measure other biological parameters
such as the mitotic index.35 However, at the start of the study
we were not in a position to decide on these.
A second weakness of our new index is its lack of external
validation. However, basing it on existing scoring systems
will reduce the risk of devising a scoring system purely for a
local situation. In addition, we have performed an internal
validation of the OSRI using a bootstrapping procedure to
guard against over-optimism.7 None of the other scores have
used such methods, which increases the chance that their
parameter values are over-optimistic and over-emphasise the
contribution of less generalisable components.
In conclusion, we have compared the ability of three dif-
ferent scoring systems for spinal metastases to predict and
distinguish patient survival. Based on the most informative
scoring items from these systems, we propose the OSRI. This
is easy to calculate without reliance on expensive and time
consuming investigations, and outperforms the previous
scores. For example: 1. A patient presenting with lung pri-
mary (very rapid growth tumour) with a poor general condi-
tion score would have OSRI = 5 + (2-0) = 7, implying a
median survival of one month (85% chance of dying within
2 months). 2. A patient presenting with myeloma (slow
growing tumour), with a good general condition score would
have OSRI = 1 + (2-2) = 1, implying a median survival of 23
months (85% chance of dying within 69 months).
Decisions regarding surgery in terminally ill patients pre-
senting with spinal metastases should take into account the
morbidity of the proposed treatment as well as life expec-
tancy. Unnecessary surgery should not jeopardise the
VOL. 95-B, No. 2, FEBRUARY 2013
215
quality of life in these patients. Similarly, when the progno-
sis is good, even radical surgery should not be withheld.
The OSRI is a useful tool, and the rates of survival quoted
in this series will help surgeons hold meaningful discussions
with patients and relatives.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
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