Spinal instability as defined by the spinal instability neoplastic score is associated with radiotherapy failure in metastatic spinal disease

BACKGROUND CONTEXT: Although radiotherapy is effective in achieving pain relief in most patients, it is not completely understood why some patients respond well to radiotherapy and others do not. Our hypothesis was that metastatic bone pain, if predominantly caused by mechanical instability of the spine, responds less well to radiotherapy than metastatic bone pain caused by local tumor activity. Recently, the spinal instability neoplastic score (SINS) was proposed as a standardized referral tool for nonspine specialists to facilitate early diagnosis of spinal instability. PURPOSE: To investigate the association between spinal instability as defined by the SINS and response to radiotherapy in patients with spinal metastases. STUDY DESIGN: A retrospectively matched case-control study in an academic tertiary referral center, conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. PATIENT SAMPLE: Thirty-eight patients with spinal metastases who were retreated after initial palliative radiotherapy from January 2009 to December 2010 were matched to 76 control patients who were not retreated. OUTCOME MEASURES: Radiotherapy failure as defined by retreatment (radiotherapy, surgery, and conservative) after palliative radiotherapy for spinal metastases. METHODS: Radiotherapy planning computed tomography scans were scored by a blinded spine surgeon according to the SINS criteria. The association between SINS and radiotherapy failure was estimated by univariate and multivariate conditional logistic regression analysis. RESULTS: Median SINS was 10 (range 4-16) for cases and 7 (range 1-16) for controls. The SINS was significantly and independently associated with radiotherapy failure (adjusted odds ratio, 1.3; 95% confidence interval, 1.1-1.5; p=.01). CONCLUSIONS: This study shows that a higher spinal instability score increases the risk of radiotherapy failure in patients with spinal metastases, independent of performance status, primary tumor, and symptoms. These results may support the hypothesis that metastatic spinal bone pain, predominantly caused by mechanical instability, responds less well to radiotherapy than pain mainly resulting from local tumor activity. (C) 2014 Elsevier Inc. All rights reserved.