. 2025 Jan;15(1_suppl):132S-142S.

doi: 10.1177/21925682231220551.

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

William Chu Kwan¹, Scott L Zuckerman², Charles G Fisher¹, Ilya Laufer³, Dean Chou⁴, John E O'Toole⁵, Markus Schultheiss⁶, Michael H Weber⁷, Daniel M Sciubba⁸, Markian Pahuta⁹, John H Shin¹⁰, Michael G Fehlings¹¹, Anne Versteeg¹², Matthew L Goodwin¹³, Stefano Boriani¹⁴, Chetan Bettegowda¹⁵, Aron Lazary¹⁶, Alessandro Gasbarrini¹⁴, Jeremy J Reynolds¹⁷, Jorrit-Jan Verlaan¹⁸, Arjun Sahgal¹⁹, Ziya L Gokaslan²⁰, Laurence D Rhines²¹, Nicolas Dea¹

Affiliations

¹ Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, BC, Canada.
² Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
³ Department of Neurological Surgery, New York University Grossman School of Medicine, New York, NY, USA.
⁴ The Neurological Institute of New York, Columbia University Irving Medical Center, New York, NY, USA.
⁵ Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA.
⁶ University of Ulm, Ulm, Germany.
⁷ Spine Surgery Program, Department of Surgery, Montreal General Hospital, Faculty of Medicine, McGill University, Montreal, QC, Canada.
⁸ Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, New York, NY, USA.
⁹ Department of Surgery, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
¹¹ Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, University Health Network, Toronto, ON, Canada.
¹² Orthopaedic Surgery, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada.
¹³ Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA.
¹⁴ Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
¹⁵ Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
¹⁶ National Center for Spinal Disorders, Budapest, Hungary.
¹⁷ Oxford Spinal Surgery Unit, Oxford University Hospitals, Oxford, UK.
¹⁸ Department of Orthopaedic Surgery, University Medical Center, Utrecht, The Netherlands.
¹⁹ Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²⁰ Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
²¹ Department of Neurosurgery, Division of Surgery, University of Texas, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

PMID: 39801116
PMCID: PMC11988250
DOI: 10.1177/21925682231220551

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

William Chu Kwan et al. Global Spine J. 2025 Jan.

. 2025 Jan;15(1_suppl):132S-142S.

doi: 10.1177/21925682231220551.

Authors

Affiliations

¹ Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, BC, Canada.
² Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
³ Department of Neurological Surgery, New York University Grossman School of Medicine, New York, NY, USA.
⁴ The Neurological Institute of New York, Columbia University Irving Medical Center, New York, NY, USA.
⁵ Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA.
⁶ University of Ulm, Ulm, Germany.
⁷ Spine Surgery Program, Department of Surgery, Montreal General Hospital, Faculty of Medicine, McGill University, Montreal, QC, Canada.
⁸ Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, New York, NY, USA.
⁹ Department of Surgery, McMaster University, Hamilton, ON, Canada.
¹⁰ Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
¹¹ Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, University Health Network, Toronto, ON, Canada.
¹² Orthopaedic Surgery, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada.
¹³ Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO, USA.
¹⁴ Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
¹⁵ Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
¹⁶ National Center for Spinal Disorders, Budapest, Hungary.
¹⁷ Oxford Spinal Surgery Unit, Oxford University Hospitals, Oxford, UK.
¹⁸ Department of Orthopaedic Surgery, University Medical Center, Utrecht, The Netherlands.
¹⁹ Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²⁰ Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
²¹ Department of Neurosurgery, Division of Surgery, University of Texas, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

PMID: 39801116
PMCID: PMC11988250
DOI: 10.1177/21925682231220551

Abstract

Study design: Systematic review.

Objective: In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries.

Methods: Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications.

Results: Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation.

Conclusion: In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Keywords: SINS; mechanical stability; metastases; oncology; surgery; tumor.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

**Figure 1.**
Flowchart summarizing literature search and study selection process.

See this image and copyright information in PMC

Cited by

Role of Denosumab in Patients with Intermediate Spinal Instability Neoplastic Score (SINS).
Lee J, Chang BS, Kim H, Kim ST, Jang S, Chang SY. Lee J, et al. Cancers (Basel). 2025 May 1;17(9):1539. doi: 10.3390/cancers17091539. Cancers (Basel). 2025. PMID: 40361465 Free PMC article.

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What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

Affiliations

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

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