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Modern Treatment of Spinal metastases
Maxwell Boakye MD MPH FACS FAANSAssociate Professor of Neurosurgery
Nelson Endowed ChairCenter for Advanced Neurosurgery University of
Louisville
My Background
bull Neurosurgeonbull Residency 2002bull Fellowships-complex spine-Emory and Spine
Oncology-Sloan Kettering-2003bull Stanford-2003-2010-worked with cyberknifebull Special interest in spine tumors and spine
radiosurgery
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
My Background
bull Neurosurgeonbull Residency 2002bull Fellowships-complex spine-Emory and Spine
Oncology-Sloan Kettering-2003bull Stanford-2003-2010-worked with cyberknifebull Special interest in spine tumors and spine
radiosurgery
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317