The Performance of Prognostic Measures for Survival in Spinal Metastatic Disease in Light of Modern Advancements in Medical and Surgical Management

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare the performance of four of the most widely used scoring systems for survival in spinal metastatic disease among a representative battery of cases treated in our health system during 2017 to 2022. SUMMARY OF BACKGROUND DATA: None of the popular risk scores in use today effectively account for improved survival due to advancements in immunotherapy, molecular targeted treatment, and surgical techniques. METHODS: We assembled a representative battery of 997 patients who underwent operative or nonoperative treatment for spinal metastases (2017-2022). All patients were assigned a Tokuhashi score, Tomita score, Skeletal Oncology Research Group (SORG), and New England Spinal Metastasis Score (NESMS) based on data at initial presentation. The primary outcome was the discriminative capacity of the scoring utilities in predicting one-year mortality. This was evaluated using multivariable logistic regression with all variables included as co-variates. The discriminative capacity for each model was compared using the c-statistic. We also assessed the performance of operative management in conjunction with the survival score. RESULTS: One-year mortality was 54%. The SORG's c-statistic was 0.75 (95% CI: 0.71, 0.78), compared with 0.68 (95% CI: 0.65, 0.71) for the NESMS. The c-statistic for the Tokuhashi score was 0.70 (95% CI: 0.67, 0.73), while that of the Tomita scale was 0.66 (95% CI: 0.63, 0.69). Only the SORG (OR: 0.64; 95% CI: 0.46, 0.90; P =0.01) and NESMS (OR: 0.74; 95% CI: 0.56, 0.97; P =0.03) preserved a significant association between surgical intervention and survival. CONCLUSIONS: We found that the performance of all scores was diminished relative to historical reports, but remained adequate for the NESMS and SORG algorithms. In current practice, we believe the optimal approach entails initial use of the NESMS when considering treatment approaches, with the SORG used for recalculating survival if surgical intervention has been selected as a treatment strategy. LEVEL OF EVIDENCE: Level III.