Drivers of Readmission and Reoperation After Surgery for Vertebral Column Metastases

Decompression surgery followed by adjuvant radiotherapy is an effective therapy for preservation or recovery of neurological function and achieving durable local disease control in patients suffering from metastatic epidural spinal cord compression (ESCC). The authors examine the outcomes of postoperative image-guided intensity-modulated radiation therapy delivered as single-fraction or hypofractionated stereotactic radiosurgery (SRS) for achieving long-term local tumor control. A retrospective chart review identified 186 patients with ESCC from spinal metastases who were treated with surgical decompression, instrumentation, and postoperative radiation delivered as either single-fraction SRS (24 Gy) in 40 patients (21.5%), high-dose hypofractionated SRS (24-30 Gy in 3 fractions) in 37 patients (19.9%), or low-dose hypofractionated SRS (18-36 Gy in 5 or 6 fractions) in 109 patients (58.6%). The relationships between postoperative adjuvant SRS dosing and fractionation, patient characteristics, tumor histology-specific radiosensitivity, grade of ESCC, extent of surgical decompression, response to preoperative radiotherapy, and local tumor control were evaluated by competing risks analysis. The total cumulative incidence of local progression was 16.4% 1 year after SRS. Multivariate Gray competing risks analysis revealed a significant improvement in local control with high-dose hypofractionated SRS (4.1% cumulative incidence of local progression at 1 year, HR 0.12, p = 0.04) as compared with low-dose hypofractionated SRS (22.6% local progression at 1 year, HR 1). Although univariate analysis demonstrated a trend toward greater risk of local progression for patients in whom preoperative conventional external beam radiation therapy failed (22.2% local progression at 1 year, HR 1.96, p = 0.07) compared with patients who did not receive any preoperative radiotherapy (11.2% local progression at 1 year, HR 1), this association was not confirmed with multivariate analysis. No other variable significantly correlated with progression-free survival, including radiation sensitivity of tumor histology, grade of ESCC, extent of surgical decompression, or patient sex. Postoperative adjuvant SRS following epidural spinal cord decompression and instrumentation is a safe and effective strategy for establishing durable local tumor control regardless of tumor histology-specific radiosensitivity. Patients who received high-dose hypofractionated SRS demonstrated 1-year local progression rates of less than 5% (95% CI 0%-12.2%), which were superior to the results of low-dose hypofractionated SRS. The local progression rate after single-fraction SRS was less than 10% (95% CI 0%-19.0%).

A prospective randomized controlled trial.

Enhanced Recovery After Surgery (ERAS) programs follow a multimodal, multidisciplinary perioperative care approach that combines evidence-based perioperative strategies to accelerate the functional recovery process and improve surgical outcomes. Despite increasing evidence that supports the use of ERAS programs in gastrointestinal and pelvic surgery, data regarding the development of ERAS programs in spine surgery are scarce. To evaluate the impact of an Enhanced Recovery After Spine Surgery (ERSS) program in a US academic cancer center, the authors introduced such a program and hypothesized that ERSS would have a significant influence on meaningful clinical measures of postoperative recovery, such as pain management, postoperative length of stay (LOS), and complications. A multimodal, multidisciplinary, continuously evolving team approach was used to develop an ERAS program for all patients undergoing spine surgery for metastatic tumors at The University of Texas MD Anderson Cancer Center from April 2015 through September 2016. This study describes the introduction of that ERSS program and compares 41 patients who participated in ERSS with a retrospective cohort of 56 patients who underwent surgery before implementation of the program. The primary objectives were to assess the effect of an ERSS program on immediate postoperative pain scores and in-hospital opioid consumption. The secondary objectives included assessing the effect of ERSS on postoperative in-hospital LOS, 30-day readmission rates, and 30-day postoperative complications. The ERSS group showed a trend toward better pain scores and decreased opioid consumption compared with the pre-ERSS group. There were no significant differences in LOS, 30-day readmission rate, or 30-day complication rate observed between the two groups. An ERSS program is feasible and potentially effective on perioperative pain control and opioid consumption, and can expedite recovery in oncological spine surgery patients. Larger-scale research on well-defined postoperative recovery outcomes is needed.