Timing of stereotactic radiosurgery and surgery and wound healing in patients with spinal tumors: a systematic review and expert opinions

Objectives Spinal stabilization surgery is an integral part of the treatment of spinal metastatic disease. Bony fusion is the hallmark of spinal stabilization in non-oncology patients. Spinal oncology patients are unlikely to achieve bony fusion due to their overall prognosis and concurrent therapies. Stabilization surgery without fusion may be a reasonable approach for these patients. Literature evaluating the effectiveness of this approach is limited. The object of this study was to investigate the rate of instrumentation failure in patients undergoing posterior spinal instrumented stabilization without fusion for spinal metastatic disease. Methods Data from consecutive cases of spinal surgery at our institution during an 81-month period were reviewed. Demographics, clinical notes, and computed tomography (CT) findings were recorded and used to evaluate instrumentation failures. Patients who underwent separation surgery that included laminectomy and posterior spinal instrumentation without fusion for spinal metastatic disease and had follow-up CT scans >3 months postoperatively were selected for the study. Results Twenty-seven patients were included in the study. Mean age was 64.85±6.53 years. Nine patients were women. A mean of 1.61±0.96 laminectomy levels was performed. A mean of 8.26±1.48 screws was inserted. The mean postoperative discharge date was 5.07±1.47 days. Mean follow-up duration was 12.17±11.73 months. None of the patients had a change in instrumentation position, pedicle screw pullout, change in spinal alignment, or progressive deformity. No patient required reoperation or instrumentation revision or replacement. Conclusions Our experience suggests that instrumented spinal stabilization without fusion is an acceptable approach for patients with spinal metastatic disease.

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“…63–65 The nutritional compromise observed in oncology patients may further preclude fusion occurrence. 38, 61 …”

Section: Discussionmentioning

confidence: 99%

Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease

2018

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“…Wound complication rates of up to 46% have been reported when EBRT and surgery were combined less than a week apart [4]. Considering the increased application of SBRT as adjuvant radiotherapy treatment Itshayek et al [5] conducted a systematic review investigating the effect of timing of SBRT and surgical treatment on the risk of wound complications. The authors concluded that due the conformal dose distribution SBRT is likely associated with a lower risk of wound complications [5].…”

Section: Discussionmentioning

confidence: 99%

“…Considering the increased application of SBRT as adjuvant radiotherapy treatment Itshayek et al [5] conducted a systematic review investigating the effect of timing of SBRT and surgical treatment on the risk of wound complications. The authors concluded that due the conformal dose distribution SBRT is likely associated with a lower risk of wound complications [5]. Yet, considering the sensitivity of the early phases of the wound healing process in tissues exposed to radiation, a time interval of at least one week between surgery and SBRT is still recommended [5].…”

Section: Discussionmentioning

confidence: 99%

“…The combination of surgery and radiotherapy has been shown to be effective in achieving pain relief, maintaining ambulatory function and improving quality of life in patients with symptomatic spinal metastases [1][2][3]. Optimal timing of surgery and radiotherapy is however crucial as radiotherapy may impair wound healing [4,5]. Surgical intervention for spinal metastases is typically followed by conventional 2D external beam radiotherapy (EBRT) for local tumor control and additional pain relief.…”

Section: Introductionmentioning

confidence: 99%

“…The conformal dose distribution of SBRT permits dose escalation to ablative radiation doses to the spinal metastasis while limiting the dose to the spinal cord and other surrounding tissues, including the skin [7,8]. Post-operative use of SBRT, rather than EBRT, is therefore likely associated with a lower risk of wound complications [5]. The use of SBRT after surgical stabilization is, however, challenging as the metallic spinal implants cause imaging artifacts and radiation backscattering prevents accurate target delineation, treatment planning and delivery [9].…”

Section: Introductionmentioning

confidence: 99%

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Sparing the surgical area with stereotactic body radiotherapy for combined treatment of spinal metastases: a treatment planning study

et al. 2018

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Introduction: Decreasing the radiation dose in the surgical area is important to lower the risk of wound complications when surgery and radiotherapy are combined for the treatment of spinal metastases. The purpose of this study was to compare the radiation dose in the surgical area for spinal metastases between single fraction external beam radiotherapy (EBRT), single fraction stereotactic body radiotherapy (SBRT) and single fraction SBRT with active sparing (SBRT-AS) of the posterior surgical area. Methods: Radiotherapy treatment plans for EBRT, SBRT and SBRT-AS of the posterior surgical area were created for 13 patients with spinal metastases. A single fraction of 8Gy was prescribed to the spinal metastasis in the EBRT plan. For the SBRT treatment plans, a single fraction of 18Gy was prescribed to the metastasis and 8Gy to the rest of the vertebral body. For the SBRT plan with active sparing the dose in the designated surgical area was minimized without compromising the dose to the organs at risk. Results: The median dose in the surgical area was 2.6Gy (1.6-5.3Gy) in the SBRT plan with active sparing of the surgical area compared to a median dose of 3.7Gy (1.6-6.3Gy) in the SBRT plan without sparing and 6.5Gy (3.5-9.1Gy) in the EBRT plans (p < .001). The radiation doses to the spinal metastases and organs at risk were not significantly different between the SBRT plan with and without sparing the surgical area. Conclusions: The radiation dose to the surgical area is significantly decreased with the use of SBRT compared to EBRT. Active sparing of the surgical area further decreased the mean radiation dose in the surgical area without compromising the dose to the spinal metastasis and the organs at risk.

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Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases

Bander,

El Ahmadieh,

Chen

et al. 2023

JAMA Netw Open

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ImportanceAdjuvant stereotactic radiosurgery (SRS) enhances the local control of resected brain metastases (BrM). However, the risks of local failure (LF) and potential for posttreatment adverse radiation effects (PTRE) after early postoperative adjuvant SRS have not yet been established.ObjectiveTo evaluate whether adjuvant SRS delivered within a median of 14 days after surgery is associated with improved LF without a concomitant increase in PTRE.Design, Setting, and ParticipantsThis prospective cohort study examines a clinical workflow (RapidRT) that was implemented from 2019 to 2022 to deliver SRS to surgical patients within a median of 14 days, ensuring all patients were treated within 30 days postoperatively. This prospective cohort was compared with a historical cohort (StanRT) of patients with BrM resected between 2013 and 2019 to assess the association of the RapidRT workflow with LF and PTRE. The 2 cohorts were combined to identify optimal SRS timing, with a median follow-up of 3.3 years for survivors.ExposureTiming of adjuvant SRS (14, 21, and 30 days postoperatively).Main Outcomes and MeasuresLF and PTRE, according to modified Response Assessment in Neuro-Oncology Brain Metastases criteria.ResultsThere were 438 patients (265 [60.5%] female patients; 23 [5.3%] Asian, 27 [6.2%] Black, and 364 [83.1%] White patients) with a mean (SD) age of 62 (13) years; 377 were in the StanRT cohort and 61 in the RapidRT cohort. LF and PTRE rates at 1 year were not significantly different between RapidRT and StanRT cohorts. Timing of SRS was associated with radiographic PTRE. Patients receiving radiation within 14 days had the highest 1-year PTRE rate (18.08%; 95% CI, 8.31%-30.86%), and patients receiving radiation between 22 and 30 days had the lowest 1-year PTRE rate (4.10%; 95% CI, 1.52%-8.73%; P = .03). LF rates were highest for patients receiving radiation more than 30 days from surgery (10.65%; 95% CI, 6.90%-15.32%) but comparable for patients receiving radiation within 14 days, between 15 and 21 days, and between 22 and 30 days (≤14 days: 5.12%; 95% CI, 0.86%-15.60%; 15 to ≤21 days: 3.21%; 95% CI, 0.59%-9.99%; 22 to ≤30 days: 6.58%; 95% CI, 3.06%-11.94%; P = .20).Conclusions and RelevanceIn this cohort study of adjuvant SRS timing following surgical resection of BrM, the optimal timing for adjuvant SRS appears to be within 22 to 30 days following surgery. The findings of this study suggest that this timing allows for a balanced approach that minimizes the risks associated with LF and PTRE.

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Timing of stereotactic radiosurgery and surgery and wound healing in patients with spinal tumors: a systematic review and expert opinions

Abstract: Evidence to guide decisions regarding the sequence and timing of surgery and SRS with respect to wound healing is limited. Consistent reporting of wound healing complications will improve ability to develop guidelines for optimal treatment of spinal tumors.

Cited by 34 publications

References 68 publications

Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease

Instrumented Spinal Stabilization without Fusion for Spinal Metastatic Disease

Sparing the surgical area with stereotactic body radiotherapy for combined treatment of spinal metastases: a treatment planning study

Outcomes Following Early Postoperative Adjuvant Radiosurgery for Brain Metastases

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