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. 2018;5(2):99-105.

Pain flare after stereotactic radiosurgery for spine metastases

Ehsan H Balagamwala  1 , Mihir Naik  2 , Chandana A Reddy  1 , Lilyana Angelov  3 , John H Suh  1   4 , Toufik Djemil  2 , Anthony Magnelli  1 , Samuel T Chao  1   4
Affiliations

Pain flare after stereotactic radiosurgery for spine metastases

Ehsan H Balagamwala et al. J Radiosurg SBRT. 2018.

Abstract

Purpose: Understanding of pain flare (PF) following spine stereotactic radiosurgery (sSRS) is lacking. This study sought to determine the incidence and risk factors associated with PF following single fraction sSRS.

Materials/methods: An IRB-approved database was compiled to include patients who underwent sSRS. Patient and disease characteristics as well as treatment and dosimetric details were collected retrospectively. Pain relief post-sSRS was prospectively collected using the Brief Pain Inventory (BPI). These factors were correlated to the development of PF (defined as an increase in pain within 7 days of treatment which resolved with steroids). Survival was calculated using Kaplan-Meier analysis and logistic regression was utilized to evaluate the association between the clinical and treatment factors and occurrence of PF.

Results: A total of 348 patients with 507 treatments were included. Median age and prescription dose were 59 years and 15 Gy (range: 7-18), respectively, and 62% of patients were male. Renal cell carcinoma (24%), lung cancer (14%), and breast cancer (11%) were the most common histologies, and 74% had epidural disease and 43% had thecal sac compression. The most common location of metastases was in the cervical/thoracic spine (59%), followed by lumbar spine (32%), and sacral spine (9%). Most common reason for treatment was pain (73%), followed by pain and neurological deficit (13%), asymptomatic disease (10%), and neurologic deficit only (3%). Median time to pain relief was 1.8 months. Median overall survival, time to radiographic failure, and time to pain progression were 13.6 months, 26.5 months, and 56.6 months, respectively. Only 14.4% of treatments resulted in the development of PF. Univariate analysis showed that higher Karnofsky performance score (KPS) (OR=1.03, p=0.03), female gender (OR=1.80, p=0.02), higher prescription dose (OR=1.30, p=0.008), and tumor location of cervical/thoracic spine vs lumbar spine (OR=1.81, p=0.047) were predictors for the development of PF. On multivariate analysis, higher consult KPS (OR=1.03, p=0.04), female gender (OR=1.93, p=0.01), higher prescription dose (OR=1.27, p=0.02), and tumor location of cervical/thoracic spine vs lumbar spine (OR=1.81, p=0.05) remained predictors of PF. No other dosimetric parameters were associated with the development of PF.

Conclusion: PF is an infrequent complication of sSRS. Predictors for the development of PF include higher consult KPS, female gender, higher prescription dose, and cervical/thoracic tumor location. Dose to the spinal cord was not a predictor of PF. Since a minority (14.4%) of treatments result in PF, we do not routinely utilize prophylactic steroid treatment; however, prophylactic steroids may be considered in female patients with cervical/thoracic metastases receiving higher dose sSRS.

Keywords: pain flare; spine metastasis; spine radiosurgery.

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Conflict of interest statement

Authors’ disclosure of potential conflicts of interest Dr. Chao reports “honorarium” from Varian Medical Systems, outside the submitted work. Dr. Suh reports grants from Varian Medical Systems and “travel and lodging” from Elekta, outside the submitted work. Drs. Angelov, Balagamwala, Djemil, Magnelli, Naik, and Reddy have nothing to disclose.

Figures

Figure 1
Figure 1
Spine radiosurgery treatment plan (axial [a] and sagittal [b]) for treatment at T9-10 (16 Gy in 1 fraction). Blue line represents the target volume contour, purple line represents the spinal cord contour. The red shaded region represents the 16 Gy dose distribution and the green shaded region represents the 10 Gy dose distribution.
Figure 2
Figure 2
Pain relief after spine SRS for patients with symptomatic spine metastases at the time of treatment (n = 439).
See this image and copyright information in PMC

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