Scoring System for the Preoperative Evaluation of Metastatic Spine Tumor Prognosis YASUAKI TOKUHASHI, MD, HIROMI MATSUZAKI, MD, SADAYOSHI TORIYAMA, MD, HISASHI KAWANO, MD, and SHUNZO OHSAKA, MD ‘An assessment system for the prognosis of metastatic spine tumors was evaluated for 64 cases who had under- gone surgery. Six parameters were employed in the as- sessment system: 1) the general condition, 2) the number of extraspinal bone metastases, 3) the number of me- tastases in the vertebral body, 4) metastases to the major internal organs (lungs, liver, kidneys, and brain), 5) primary site of the cancer, and 6) the severity of spinal cord palsy. Each parameter ranged from Oto 2 points. The total score obtained for each patient can be correlated with the prognosis, while being valuable in predicting it. However, the prognosis could not be predicted from a single parameter. In conclusion, an excisional operation should be performed on those cases who scored above 9 Boints, while a palliative operation ig indicated for those Who scored under 5 points. [Key words: prognosis evalu- ation system, metastatic spine tumor] ‘erventions inthe treatment of spinal cord palsy and progressive pain originating from a vertebral collapse due to metastatic spine tumors or cancer, Various excisional procedures, including extensive cerettage on the vertebral body supplemented by special prosthesis (ceramic spacer, ec.) or cement with or without instrumentation, have ‘been attempted for the purpose of improving the patient's period of ‘survival. For patents with a poor prognosis, only palliative procedures are carried out to provide suppor: with various type of posterior instrumentation (Harrington, Luque, transpedicular fixation, et.) with ‘or without laminectomy. Because of the difficulty of establishing a ‘prognosis fr those patients, however, the selection ofthe mast suitable procedure often calls for painstaking deliberations. We therefore attempted fo set up a simple scoring system for the preoperative evaluation of the prognosis of metastatic spine tumors or cancer with spinal cord palsy and progressive pain, based on our experience with patents who had been surgically treated. Te aim ofthis articles isly to report on the scoring system, and secondly fo discuss the operative procedures selected with reference to it SUBJECTS AND METHOD Patients Studied. The subjects consisted of 64 patients who had been surgically treated at the Department of Orthopaedics, Nihon University between 1978 and 1988. Of those, five were ill alive as of May 1989. Classified by gender, there were 41 men and 23 women, and theirages ranged from 16 076, the mean being 55.4. The mos frequent site ofthe vertebra was the thoracic spine (32 cases, 42.7%); followed I: RECENT YEARS there has often been a preference for surgical From he Deparment of Onioosie Suge, Nikon Unive, Seo! ot asin, Tako. peas " ‘Stim Tor pbliaon March 1, 1980, by the lumbar pine (27 cases), the cervical spine (13 cases), and the sacral spine (thre cases). As forthe onder of incidence ofthe primary lesion, breast cancer was incriminated in nine cases, kidney cancer in six, lung cancer in sx, prostate cancer in five, rectum cancer in five, liver cancer in five, emus cancer in four, others (thyroid cancer, bladder cancer, gallbladder cancer, osteosarcoma, el.) in 11, and the crigin unidentified in 13 cases. Vertebral collapses resulting from smple myeloma were excluded from the present series. “The surgical procedures were classified into two groups. One was the excisional procedure, which aimed at proving support for and pro- Tonging the life of the patent, consisting of extensive curettage with reconstruction using a special prosthesis (eramie spacer, et.) (three cases) cement combined with instrumentation (two cass), and cement without instrumentation (six cases). This procedure also consisted of the anterior approach (seven cases), the posterior approach (one case), and th anterior approach combined withthe posterior approach (ree cases), The other Was the palliative procedure, aimed ony at securing support. Ths procedure included instrumentation (Harrington, Luque, etc.) with decompression (21 eases) or without it (26 cases), and laminectomy only (sx cases). Method. Six parameters were employed in the evaluation system to asces the severly of the vertebral collapse resuling from metastatic spine tumors: 1 general condition, 2) the numberof extraspinal bone ‘metastases foc, 3 the numberof metastases in the vercbral body, 4) ‘metastases 10 the major internal organs (lungs, liver, kidneys, and train), 5) the primary st ofthe cancer, and 6) the severity of spinal, cord paly. These parameters were temporarily graded from 0 0 2 (abe To asess the general condition, the criteria established by Kamofsky forthe performance status wer applied, giving 2 points for ‘rating between 80 and 100%, rating ita "god," point for between ‘0 and 70%, rating ita “moderate,” and O points for between 10 and ‘number of exttaspinal bone metastasis foci was in principle determined on the basis of the findings ofthe bone scans. Fora large bone lke the pelvis, the sites ofthe uptake were counted as the number ‘of metastases. Zero points were given when there were three or more such sites, I point when there was one or tWo, and 2 points when there was no other extraspinal bone metastases. For the number of metastases in the vertebral body, a vertebra constituted one siteand when the lesion had infiltrated over the disk, the condition was regarded as being two metastases. “Metastases to the major internal organs were diagnosed using chest cay photography, computed tomography (CT), sonography, scntig- raphy et. Patients with no metastases fo these organs scored 2 points; those with a metastasized lesion removable by an operation, | point;and those with metastases unremovable by an operation, 0 points ‘The primary site ofthe cancer was studied in relation to the average period of postoperative survival (Figure 1). As a result, the average period of survival was found tobe less than 3 months for patients with the primary lesion nthe lung or stomach; and more than I year for those inthe thyroid, breast, prostate, or rectum, Consequently, 0 points were given to those with a primary lesion in the lung or stomach; | pont to‘Tablo 1. Evaluation Systom for the Prognosis of Metastatic Spine Tumors 1. General condition (performance status) Score Poor (PS 10-40%) 0 Moderate (PS 50-70%) 1 Good” (PS 80-10%) 2 2, Number of extraspinal bone metastases foci 33 ° 42 1 ° 2 8, Numbor of metastases in the vertebral body 23 o 2 1 1 2 4. Metastases to the major internal organs Unremavable 0 Removable 1 No metastases 2 5. Primary site ofthe cancer ‘Lung, stomach ° Kidney, Iver, uterus 1 Others, unidentified Thyroid, prostate, breast 2 Rectum 6. Spinal cord palsy ‘Complete Incomplete None those the kidney, liver, uterus, bladder or gallbladder; and 2 points to those in te thyroid, breast, prostate orrectum. The metastatic cases. of unidentified origin (unidentified) and the cases of single incidence (ers) scored I point, respectively, in the present series. ‘The severity of spinal cord palsy was classified into thee grades based on the findings from Frankel’s classification: Frankel’s A or B type was regarded as complete palsy, scoring 0 points; Frankel’s CorD Scoring 1 points; and the neurologically normal condition scoring 2 points Each score andthe grand total (maximum: 12 points) were studied in relation to the prognosis, and their possibility as criteria for operative indication was examined, RESULTS General Condition Versus the Survival Period Fifty-one (79.7%) of the patients were in the hospital when the vertebral collapse occurred and the symptoms (progressive pain or neurologic deficiency) developed. Based on the general condition, the : La | , : A i = l Ht fezaleca] Fig 1. Relationship between the tumor origin and the survival period alier a surgical intervention into the spine. SPINE TUMOR PROGNOSIS SCORING + TOKUHASHI ET AL 1111 ‘mean period of postoperative survival + standard deviation (SD) were 4.2 © 3.0 months for the Score 0 Group (13 cases); 3.1 * 2.5 months for the Score 1 Group 21 eases); and 11.9 % 11.8 months forthe Score 2Group (30 cases) (Figure 2). It seemed inappropriate to rely solely on the score forthe general condition to establish the prognosis, asthe standard deviation was too ‘great for the values tobe sufficiently meaningful Number of Extraspinal Bone Metastases Foci Versus the Survival Period Extraspinal osseous metastases were particularly frequent in the pelvis and ribs. AS forthe long tubal bones. the femur and humerus often were involved. Twenty-five cases (39.1%) were found to have no other osseous metastases and therefore scored 2 points. Twenty-seven cases (42,26) had thre or more metastases to other bones (0 points). ‘This finding suggested that, in about half of the cases, multiple metastases had already existed when the vertebral collapse occured and the symptoms developed. Regarding the period of postoperative survival, the Score 0 group survived 4.4 + 4.1 months, the Score | group 6.3 + 6.8 months, and the Score 2 group 12.0 = 12.4 months (Figure 2) ‘Number of Metastases in the Vertebral Body Versus the Survival Period The type of metastases inthe vertebral body was found to vary, soit ‘was not always the continuous type. Regarding the period of postoper- ive survival, the Score 0 group (> 3) survived 4.3 = 4.0 months, the Score 1 group (2) 5.25.3 months, and the Score 2 group (1) 13.3 + 13.1 months (Figure 2). Metastases to the Major Internal Organs Versus the Survival Period ‘When the cancer had metastasized tothe lung, liver, or brain, the lesion was usually inoperable. Only one casein this series was operable ‘and therefore scored 1 point. In view of the future progress in early cancer detection and inthe surgical treatment of metastases tothe major intemal organs, however, a Score | group category was set up independently. The average period of postoperative survival SD was 3.4 © 2.3 months forthe Score 0 Group (29 cases) with inoperable ‘metastases in one of the major intemal organs. This was significantly shorter than that forthe group without such metastases (Score 2 group; 30 cases), being 12.0 + 11.9 months (Figure 2). Primary Site of the Cancer Versus the Survival Period ‘With regard tothe primary ste ofthe cancer, the average survival ‘period forthe Score 0 group (lung, stomach) was 2.4 = 1.4 months Mss 0 Coser | Biore 2 Fig 2 Comparison of the prognosis for each parameter (general ‘condition, gan cond; number of exiraspinal bone metastases foci texttasp bo; number of metastases inthe vertebral body, ver body: ‘molastases tothe major internal organs, major .o.; primary site ofthe ‘cancer, primary ste; spinal cord palsy, palsy).1112 SPINE + VOLUME 15 + NUMBER 11 + 1990 (a= 9) forthe Score 1 group (kidney, liver, uterus, “thers,"“uniden- tified”), 4.9 + 3.4 months (n= 34); and for the Score 2 group, 13.1 13.6 months (a = 21) (Figure 2). All ofthe 13 “unidentified” cases were of adenocarcinoma, and their average survival period was 4.8 43.3 months. Spinal Cord Palsy Versus the Survival Period Complte palsy (rankel's A and B) (0 point) was found in 16 ofthe 6 patients (25.0%), the average survival period being 3.7 = 3.9 months. Converse, the group without a neurologic deficiency (2 points) survived for 10.4 * 13.6 manths (13 patients, 20.35) igure). Total Score Versus the Survival Period As previously mentioned, the standard deviation for each parameter was too great o form a prognosis from a single parameter. The scores foreach item were therefore totaled foreach patent, and compared with the postoperative survival period. twas found that the total score (maximum, 12 points) obtained For ‘ach patient could be corelated withthe survival period toa I% degree of significance (Figure 3) ‘The average period of survival was found to vary, asshown in Figure 4, among the grougs who had otal score ranging from Oto 12. While the patients with a total score of 9 or higher survived an average of 12 ‘months or more, those wih 8 or lower survived 12 months or les; and those with Sor lower, in pacular, only 3 months or less. Operative Method Versus the Survival Period ‘The average of the total scores for each operative method was compared with each average survival period. The average total score for the excisionally treated group (11 cases) was 8,7 2.7, and the average survival period was 11.6 + 12.0 months. The paliatively tweated group receiving posterior instrumentation with or without decompression (53 cases), however, had an average total score of 5.7 3.0 and a survival period of 6.4 + 8.8 months, Because ofthe large standard deviation inthe total score and the survival period fr the excisionally treated groups, it might be argued, retrospectively, that the thee cases (27.3%) with atoal score of 5 or less out of the 11 should hhave been treated palliatively DISCUSSION The spine is the most common site for skeletal metastases, with a percentage rato of about 70 to 75% in bone metastases." Recently, out of consideration for the “quality of life,” the number of cases of operative treatment hasbeen increasing, The indications, opportunities, and methods for operative treatment ae stil being hotly debated.* The TOTAL SooRE vo pROROSIS survive) gor edtnean 7 Tore score e818 Flg 3. Correlation between the total score and the survival period. © dead 8 © alive (siB0k) sisouBosg Or23¢56789 ND Score Fig 4, Relationship between the total score and the survival period (mean * $0). indications fr operative teaiment are generally said to be progressive pain from raioresistant tumors, spinal cord palsy, and an unstable spine due to vertebral dysructon.*** As forthe opportunites, reported thatthe rapidity of the onset of muscular weakness has a considerable bearing on theultimate pognosis.® When there isa delay of less than 24 hours between the onset of the symptoms and the appearance of a full-blown neurologic syndrome, the prognosis for recovery is poor no matter what etme is offered? Conversely, the {ype of treatment, including radiation, must be selected as soon as possible, when the neurlogi syndrome develops. ‘The operative methods canbe roughly divided into two categories: excisional and palliative. The excisional method consss of extensive curetage of the metastatic Ision along with prosthesis, cement, or instrumentation, The palliative method aims only at seeing support with no o only partial resection ofthe lesion. Although thee are many surgical methods to choose from, the prognosis, an important factor selecting the most suitable procedure, isin most cases very dificult 0 establish In quite a fe cases, the excisional procedure, conducted in the hope of prolonging the patients ives, ony esuked in their de within3 months, rina postoperative infection, lading to an additional stayin hospital for most ofthe already short period of life remaining. It is therefore important to deduce the progrosis with reliable accuracy. For this purpose, the establishment of a number of trial assessment systems for the prognosis of metastatic spine tumors has been tempted using bone scans.» Yamashita etal reported thatthe‘metastases tothe major internal organs affected the prognosis more than the extent ofthe tumor spread on the bone scan, although it was useful in deducing the prognosis. In the present study, therefore, the authors aempted to examine retrospectively the six factors affecting the prognosis of metastatic spine tumors. As a result, it was found that no single parameter indicated the prognosis with reliable accuracy and, ‘consequently, a scoring system was contrived for assessing the severity of vertebral destruction due to metastatic spine tumors by combini scores for several parameters. Te total score then proved tobe highly correlative tothe postoperative survival period. While the patents with total score of Sor lower survived 3 months or less on average, those Operations Score oon Palliative methods —- Nora N © o Fig 5. indication of surgery for metastatic spine tumors with refer- ence tothe total score, SPINE TUMOR PROGNOSIS SCORING + TOKUHASHI ET AL 1113 ‘with 9 or higher survived 12 months or more, It may follow that an excisional method is indicated for a ttal score of 9 or more, while Palliative methods strongly indicated fora score of Sor less (Figure 5), ‘The present scoring system is ony a tentative one. In the future, this system will have to be modified by the parameters affecting the ‘prognosis that emerge from more experience and data. OF the above ‘parameters, the classification of the primary site ofthe cancer tends to ‘be modified as more data is accumulated, although it shouldbe kept in rind that the primary consideration is tobe given not fo the nature ofthe ‘original lesion but to its effects on the metastatic lesions. Furthermore, the progres of early diagnosis, the surgical treatment ‘of metastases to the major internal organs, and adjuvant therapy will affect the prognosis of metastatic spine tumors, and will also cause the scoring system to be modified. With more accumulated data and repeated revisions, a better scoring system for selecting the most suitable treatment should be developed, so thatthe quality of lie of terminally il patients will be upgraded without jeopardizing the prog- CONCLUSION ‘A tial assessment system forthe prognosis of patents with meta state spine tumors having undergone an operation was evaluated for 64 patients, According to our system, an excisional operation should be performed on those eases who scored more than 9 points, while a palliative operation is indicated for those scoring less than 5 points. REFERENCES 1. 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Rinsho Seki Geka 21-45-50, 1986 Address reprint requests to Yasuaki Tokuhashi The Department of Orthopaedic Surgery Nilion University Schoo! of Medicine 30-1 Oyaguchi-Kamimachi Itabashi-ku, Tokyo 173, Japan ‘Accepted for publication uly 15,1990.