bims-rebome 2025-11-16 papers

Eur Spine J. 2025 Nov 12.

Diagnostic errors in spinal metastases: a systematic review of contributing clinical and systemic factors.

STUDY DESIGN: Systematic review.
OBJECTIVES: To systematically review diagnostic errors in patients with spinal metastases, focusing on clinical, radiologic, and systemic factors contributing to missed or delayed diagnoses. This review addresses the clinical gap of delayed recognition, clarifies patterns of misdiagnosis, particularly in cases of spinal cord compression, and provides evidence to guide early detection and improve care pathways.
METHODS: We conducted a comprehensive literature review of 51 peer-reviewed studies reporting diagnostic pathways and clinical outcomes in patients with spinal metastases. Articles were analyzed for documented reasons underlying misdiagnoses, including cognitive bias, missed red flags, imaging misuse or delay, absence of known cancer history, failure to order MRI, and lack of a documented differential diagnosis. Studies were categorized thematically and synthesized based on frequency and context of these contributing factors.
RESULTS: Misdiagnosis of spinal metastases as mechanical back pain occurred frequently. Six studies explicitly reported misdiagnosis rates, with 40-70% of cases initially attributed to benign etiologies. Contributing factors included missed red flags (88.2% of studies), cognitive bias (64.7%), imaging misuse/delay (60.8%), lack of a known cancer history (19.6%), failure to order MRI (23.5%), and absence of a documented differential diagnosis (15.7%).
CONCLUSIONS: Misdiagnosis of spinal metastases as mechanical back pain remains common, even in patients presenting with red-flag symptoms. Diagnostic delays are frequently due to cognitive heuristics, inappropriate imaging, or the absence of documented diagnostic reasoning. Early recognition and appropriate imaging are critical to prevent neurologic deterioration. Increased clinical awareness and diagnostic vigilance may improve outcomes for patients with metastatic spinal disease. By addressing the previously under-recognized clinical gap in early detection, this review highlights the need for heightened clinical awareness and systematic diagnostic vigilance to prevent neurologic deterioration.

Keywords: Cognitive bias; Diagnostic delay; MRI; Mechanical back pain; Misdiagnosis; Red flags; Spinal cord compression; Spinal metastases

DOI: https://doi.org/10.1007/s00586-025-09584-4

Cancers (Basel). 2025 Nov 06. pii: 3578. [Epub ahead of print]17(21):

Management of Musculoskeletal Oligometastatic Disease in Breast Cancer.

Kelly Kon-Liao, Josue Layme, Andrea Otero López-Lavalle, Marcos R Gonzalez, Juan Pretell-Mazzini.

Oligometastatic breast cancer represents an intermediate state between localized and disseminated disease with reasonable potential for clinical cure. Advancements in surgery, radiotherapy, and systemic therapy have improved prognosis. Due to the high prevalence of bone metastases, an increasing number of studies are evaluating new treatment strategies for oligometastatic bone disease. The decision to perform skeletal surgery is complex and depends on optimal patient selection. Major criteria include impending or pathologic long bone fractures, severe neurologic compromise, and an expected survival of over 3 months. Factors associated with improved survival include solitary bone metastases, preserved performance status, adequate surgical margins, absence of pathologic fracture, metachronous metastases, and ER-positivity status. Radiotherapy, especially SBRT, offers effective local control and palliation. Interventional radiology techniques such as percutaneous thermal ablation have also been described as potential treatment alternatives, particularly for fragile patients. Systemic treatment varies according to the tumor subtype. For HR+ and HER2 subtypes, a combination of endocrine therapy with CDK4/6 inhibitors may be considered. HER2+ patients are often treated with HER2-targeted therapies combined with chemotherapy. For triple-negative breast cancer, chemotherapy is the primary treatment. Bone-modifying agents are also recommended to maintain bone strength, prevent skeletal-related events, and reduce the need for additional interventions. Skeletal muscle metastases in breast cancer patients are rare and typically indicate advanced disease with poor prognosis. Treatment options include chemotherapy, radiotherapy, and surgical excision, but should be tailored to the patient's clinical condition and prognosis.

Keywords: bone disease; breast cancer; musculoskeletal disease; oligometastasis; treatment

DOI: https://doi.org/10.3390/cancers17213578

Neurosurgery. 2025 Nov 11.

Predictors of Kyphoplasty Failures Requiring Surgical Stabilization in Patients With Cancer With Pathological Vertebral Body Fractures.

Graham M Winston, Rabih Bou Nassif, William C Newman, Eric Lis, Francois H Cornelis, Justiss A Kallos, Ryan Khanna, Vikram Chakravarthy, Anne S Reiner, Mark H Bilsky, Ori Barzilai.

BACKGROUND AND OBJECTIVES: Pathological vertebral compression fractures (VCFs) cause significant morbidity in the population with cancer. Although both stabilization of fractures with kyphoplasty and pedicle screw fixation can alleviate pain and prevent neurological compromise in select patients, there are no criteria demarcating which patients can be treated with kyphoplasty alone vs pedicle screw fixation, particularly for those with intermediate spinal instability. The objective of this study was to identify predictors of kyphoplasty failure requiring subsequent surgical stabilization in patients with metastatic thoracolumbar VCFs.
METHODS: Patients who underwent single or 2 level kyphoplasty for pathological VCFs between 2015 and 2020 were included in a retrospective analysis at a tertiary cancer center. The primary outcome measure was kyphoplasty failure, defined as return to the operating room for pedicle screw fixation. Hazard ratios (HR) were estimated in the competing risks setting. Thresholds for variables were identified where possible.
RESULTS: Forty-two of 445 patients (9.8%) failed kyphoplasty, with an average time to failure of 318 days and a 5-year cumulative incidence of 10.3% (95% CI: 7.5%-13.6%). We found focal kyphotic angle (HR 1.09, 95% CI: 1.05-1.12, P < .0001), Spinal instability neoplastic score (HR 1.16, 95% CI: 1.05-1.28, P = .03), spinal canal compromise (HR 1.05, 95% CI: 1.03-1.07, P < .0001), and posterior element involvement (HR 1.93, 95% CI: 1.03-5.63, P = .04) to be significantly associated with increased risk of kyphoplasty failure even after mutual adjustment in the multivariable setting. There were no significant associations between kyphoplasty failure and sex, age at kyphoplasty, anatomic location, or quality of bone lesion.
CONCLUSION: Kyphoplasty failure in metastatic VCFs is associated with specific radiographic markers of spinal instability. Patients with spinal instability neoplastic score ≥11, posterior-element involvement, canal compromise, and significant kyphosis may benefit from up-front surgical stabilization with pedicle screws, particularly for patients with anticipated long-term survival.

Keywords: Kyphoplasty; Minimally invasive spine surgery; Pathological compression fracture; SINS score; Vertebral compression fracture; Vertebral metastases

DOI: https://doi.org/10.1227/neu.0000000000003846

EFORT Open Rev. 2025 Nov 03. 10(11): 842-850

Comparative outcomes of internal fixation versus prosthetic reconstruction in the treatment of proximal femoral metastases: a systematic review and meta-analysis.

Ya-Shih Lai, Shu-Han Chuang, Yi-Jie Kuo, Shun-Jen Cheng, Yu-Pin Chen.

Background: Metastatic disease frequently causes pathological fractures, particularly in the proximal femur, significantly impacting patient prognosis and quality of life. With the advancements in cancer treatment leading to longer survival, there is a pressing need to evaluate the outcomes of surgical interventions aimed at managing proximal femoral metastases. This study compares the outcomes of internal fixation (IF) versus prosthesis (P) in the treatment of proximal femoral metastases, focusing on survival times, complication rates, functional outcomes, and reoperation rates.
Method: A systematic review and meta-analysis were conducted, searching PubMed, Embase, and Cochrane databases for studies published up to December 31, 2023. The PRISMA guidelines were followed. Studies comparing IF and P for proximal femoral metastases were included. Data on survival times, blood loss, reoperation rates, and functional scores were extracted and analyzed using the forest plot technique and inverse variance method. The quality of included studies was assessed using the Newcastle-Ottawa scale.
Results: In total, 19 studies (16 retrospective and three prospective) involving 4,126 patients were included. The P group demonstrated significantly longer survival times compared with the IF group, with no significant difference in complication and reoperation rates between the two methods. However, IF was associated with shorter operative times and less blood loss.
Conclusion: P may provide superior long-term functional outcomes and extended survival compared with IF, with similar rates of complications and reoperations. However, selection bias - where healthier patients with better baseline physiology are more likely to undergo prosthetic reconstruction - significantly impacts the interpretation of these findings, underscoring the need for further prospective studies.

Keywords: femoral metastases; internal fixation; meta-analysis; prosthesis; reconstruction

DOI: https://doi.org/10.1530/EOR-2024-0131