Effects of Sarcopenia and Nutritional Status on Surgical Outcomes for Metastatic Spinal Tumors : In the Perspective of Peri-operative Complications and Performance Improvement

Effects of Sarcopenia and Nutritional Status on Surgical Outcomes for Metastatic Spinal Tumors : In the Perspective of Peri-operative Complications and Performance Improvement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Sarcopenia and Nutritional Status on Surgical Outcomes for Metastatic Spinal Tumors : In the Perspective of Peri-operative Complications and Performance Improvement Chungwon Bang, Myung-Sup Ko, Young-Il Ko, Young-Hoon Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4487908/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Oct, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted 10 You are reading this latest preprint version Abstract Background With the advancement of cancer treatment, appropriate treatment for musculoskeletal problems is becoming more important as it extends the patient's lifespan and improves the quality of life. In surgical treatment for metastatic spine tumors (MST), various efforts are being considered to obtain a good prognosis. The purposes of this study are to analyze prognostic factors for postoperative ambulation and perioperative complications in patients surgically treated for MST with neurologic symptoms. Methods Seventy five cases of patients who underwent surgery for MST with neurologic symptoms were enrolled between December 2016 and January 2023. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. We defined the improvement of ambulatory function as improvement in ECOG scale. For complications, we applied complication classification system for orthopaedic surgery. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient’s admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. Prognostic factors were collected and analyzed for relationship by logistic regression. Results Of the 75 cases, postoperatively 42 (56%) cases of patients were improved in Nurick grade, 36 (48%) cases of patients in ECOG performance. And 21 (28%) cases of patients were treated in ICU and 15 (20%) cases of patients suffered from major perioperative complications. Regression analysis showed that clinical factors such as ECOG, PMI and PNI were related to the improvement of ambulatory function and incidence of perioperative complications. On multivariate analysis, improvement of ambulatory function was associated with PMI (p = 0.014) and incidence of perioperative complications was associated with PNI (p = 0.045). Conclusions Preoperative nutritional status and sarcopenia are related factors in the outcome of surgical treatment for MST, and preoperative efforts to improve these may be a way to obtain better clinical results. Metastasis Spine Complications Nutritional status Sarcopenia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Life expectancy and quality of life of patients with cancer are improving due to effective managements. For solid tumors, clinical incidence of spinal metastases is about 15% and surgical treatments for metastatic spinal tumor (MST) are increasing and prognosis of such patients is more important than before [ 19 , 28 ]. There are several studies about prognostic factors in surgical treatment for MST. Majority of these studies were focused on cord compressing metastatic lesion and analyzed outcomes were mostly ambulatory functions after surgery. Preoperative ambulation is the most important prognostic factor based on results of several [ 12 , 18 , 22 ]. Sarcopenia and nutritional factor have been emphasized for better functional outcomes after surgery in several studies recently [ 29 , 26 , 20 , 30 ]. Thus, we assessed sarcopenia and nutritional factor in the present study. It has been reported that postoperative complications are more frequent and critical in prognosis of MST patients [ 16 , 14 , 10 , 9 ]. Therefore, we also investigated prognostic factors for perioperative complications. Materials and methods This study was approved by the institutional review board, which waived the requirement for participant informed consent owing to the retrospective nature of the study (No. 2024-1177-0001). A total of 112 MST cases were surgically treated at our institute between November 2016 and December 2022. Surgical indications were severe painful symptoms with MST whose general condition were candidate for spinal surgery. Patients with axial pain only and simple decompression or fixation surgery were excluded. The general aim of surgery was to decompress neural compressing lesions and/or reconstruct the spinal alignment for stability by anterior or posterior or anteroposterior approaches. Of 112 cases, 37 cases had no neurologic symptoms but only axial pain related to mechanical instability. Thus, they were excluded from this study. Four patients had two surgeries and one patient had three surgeries in another level which was not considered as recurrence in the surgical level. Finally, 75 cases in 69 patients were included in this study. Information investigated in this study included demographics, length of stay in hospital (LoS), locations, primary tumor, the 5-item modified frailty index (mFI-5), Charlson Comorbidity Index (CCI), time interval between symptom onset and surgery (TIS), decompressed level, perioperative Eastern Cooperative Oncology Group performance status [ 21 ], perioperative Nurick grade, prognostic nutritional index (PNI), spinal instability neoplastic score (SINS), epidural spinal cord compression (ESCC) scale, psoas muscle index (PMI), intensive care unit (ICU) stay, and postoperative complications. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. ECOG scale rather than Nurick grade system was used since Nurick grade was for cord compression disease [ 23 ] and we defined the improvement of ambulatory function as improvement in ECOG scale. For complications, we applied complication classification system for orthopaedic surgery [ 25 ]. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient’s admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. For all statistical analyses, SPSS 24.00 software was used. Univariate and multivariate analyses were done. Median value was used as a cut off. Variables associated with postoperative ambulatory functions and complications were determined as a significant prognostic factor in univariate analysis ( p < 0.2). Logistic regression was then performed for prognostic factor analysis. Results The average age of patients analyzed in this study was 61.8 years (range, 26–83 years). Most (62.6%) patients were females. The mean LoS was 21 days (range, 4–74 days). Mean ICU stay was 0.53 days (range, 0–5 days). The most common sites of primary tumor and spinal location of spinal tumor were lung (30.6%) and thorax (41.3%), respectively (Table 1 ). Table 1 Patients characteristics LoS, length of stay in hospital; ICU, intensive care unit Patients Value Age 61.8 (26–83) years (range) Sex (male/female) 28/47 cases LoS 21 (4–74) days (range) ICU 0.53 (0–5) days (range) Site of primary tumors cases (%) Lung 23 (30.6) Prostate 9 (12) Breast 8 (10.6) Kidney 7 (9.3) Myeloma 6 (8) Colorectal 4 (5.3) Liver 3 (4) Hepatobilliary 2 (2.6) Gastric 2 (2.6) Lymphoma 2 (2.6) Thyroid 1 (1.3) Others 8 (10.6) Location of spinal tumor cases (%) Cervical 14 (18.6) Thoracic 31 (41.3) Lumbar 30 (40) Postoperative change was evaluated by Nurick grade and ECOG performance status. Nurick grade was improved in 50% of cases postoperatively. However, 48% of cases were unchanged (Fig. 1). Similarly, ECOG performance status was improved in 41% of cases whereas 57% of cases were unchanged (Table 2 , Fig. 2). Table 2 Change of postopertive ambulatory function ECOG, Eastern Cooperative Oncology Group performance status Postoperative status Number of patients (%) Nurick grade Improved 42 (56.0) Unchanged 32 (42.7) Worsened 1 (1.3) ECOG performance Improved 36 (48.0) Unchanged 38 (50.7) Worsened 1 (1.3) Patients were divided into myelopathy and radiculopathy alone groups. Their postoperative ambulation and complications were then investigated. Both postoperative ambulation and complications showed no significant difference in distribution between the two groups (Figs. 3, 4). In univariate analysis, significant prognostic factors for improvement of postoperative ambulation and occurrence of perioperative complications were investigated respectively. For logistic regression, we divided variables into two groups based on their median values. Tumor location was divided into cord level or not. Postoperative ambulation mFI-5, preoperative ECOG status, preoperative Nurick grade, ESCC, and PMI were associated with improvement of postoperative ambulation ( p < 0.2) (Table 3 ). Among those factors, we excluded Nurick grade which showed the same result as ECOG status to enhance the statistical power of multivariate regression analysis. In multivariate analysis, preoperative ECOG (RR: 6.699; 95% CI: 1.907–23.538, p = 0.003) and PMI (RR: 4.741; 95% CI: 1.369–16.427, p = 0.014) were found to be significantly associated with postoperative ambulation (Table 4 ). Table 3 Univariate association with the postoperative ambulation CI, confidence interval; mFI-5, 5-item modified frailty index; CCI, Charlson Comorbidity Index; TIS, time interval between symptom onset and surgery; ECOG, Eastern Cooperative Oncology Group performance status; PNI, prognostic nutritional index; SINS, spinal instability neoplastic score; ESCC, epidural spinal cord compression; PMI, psoas muscle index Variable 95% CI P value Age 0.276–1.704 0.416 Sex 0.679–4.543 0.244 Location of spinal tumor 0.672–4.372 0.258 mFI-5 0.133–1.203 0.097 CCI 0.582–3.594 0.426 TIS 0.725–4.529 0.202 Decompressed level 0.416–2.579 0.941 Preoperative ECOG 1.377–9.263 0.008 Preoperative Nurick 1.377–9.263 0.008 PNI 0.384–2.351 0.912 SINS 0.592–3.672 0.404 ESCC 0.084–1.054 0.052 PMI 0.853–5.625 0.101 Table 4 Multivariate analysis with the postoperative ambulation CI, confidence interval; ECOG, Eastern Cooperative Oncology Group performance status; ESCC, epidural spinal cord compression; PMI, psoas muscle index Variable Multivariate relative risk (95% CI) P value Preoperative ECOG 6.699 (1.907–23.538) 0.003 ESCC 0.266 (0.064–1.096) 0.067 PMI 4.741 (1.369–16.427) 0.014 Perioperative medical complications A total of 15 (20.0%) cases had confirmed medical complications. Three cases expired. There were the most severe complications (Fig. 5). In univariate analysis, mFI-5 and PNI were associated with perioperative complication ( p < 0.2) (Table 5 ). In multivariate analysis, PNI (RR: 0.278; 95% CI: 0.079–0.974, p = 0.045) was found to be significantly associated with perioperative complications (Table 6 ). Table 5 Univariate association with the perioperative medical complications CI, confidence interval; mFI-5, 5-item modified frailty index; CCI, Charlson Comorbidity Index; TIS, time interval between symptom onset and surgery; ECOG, Eastern Cooperative Oncology Group performance status; PNI, prognostic nutritional index; SINS, spinal instability neoplastic score; ESCC, epidural spinal cord compression; PMI, psoas muscle index Variable 95% CI P value Age 0.282–2.718 0.817 Sex 0.377–4.099 0.720 Location of spinal tumor 0.318–3.174 1.000 mFI-5 0.725–8.017 0.186 CCI 0.580–5.798 0.298 TIS 0.263–2.543 0.729 Decompressed level 0.368–3.562 0.816 Preoperative ECOG 0.263–2.543 0.729 Preoperative Nurick 0.263–2.543 0.729 PNI 0.079–0.974 0.038 SINS 0.322–3.108 1.000 ESCC 0.216–3.730 1.000 PMI 0.406–3.970 0.681 Table 6 Multivariate analysis with the perioperative medical complications Variable Multivariate relative risk (95% CI) P value PNI 0.278 (0.079–0.974) 0.045 CI, confidence interval; PNI, prognostic nutritional index Discussion The present study on 75 cases of surgical treatment for metastatic spinal tumor with neurologic symptoms had two major findings. Frist, improvement of postoperative ambulatory functions were associated with preoperative PMI. Second, perioperative complications were associated with preoperative PNI. Even though these results were not different from previous studies, there were some differences in the present study. Most study of prognostic factor analysis in metastatic spinal tumor were associated with cord lesion [ 7 , 12 , 18 ]. However, as radiculopathy with severe pain could reduce ambulatory function, we decided to investigate all patients with neurologic symptoms. In terms of prognostic factors, we analyzed PMI for psoas muscle and PNI for nutritional factor which were found to be beneficial in spine surgeries [ 27 , 8 , 1 , 20 ] and also in MST, status of psoas muscle and nutrition is important for improvement of ambulatory function and prevention of perioperative complications. In the present study, mFI-5 was associated with both postoperative ambulation and complications with relative significance in univariate analysis, similar to previous studies [ 3 , 15 , 24 ]. However, mFI-5 was not a significant prognostic factor for postoperative ambulation or complications in multivariate analysis, different from PMI and PNI. Because PMI and PNI are more objective data than mFI-5, those variables could reduce the recall bias. They were confirmed to be more significant prognostic factors in multivariate analysis. Most studies have revealed that preoperative ambulation is the most significant prognostic factor for postoperative ambulatory function [ 5 , 7 , 12 , 22 , 18 ], similar to results of the present study. Most studies have grouped ambulatory functions using a binary method such as ambulatory or not. However, natural course of neurologic recovery is ambiguous. Adequate time for recovery is especially hard to be defined well [ 17 , 13 , 11 ]. Therefore, more precise and quantitative assessments for ambulatory function to find out a subtle improvement could be meaningful not only for ambulatory function itself, but also for potential neurologic recovery in the future. Previous studies have reported several clinical and laboratory predictors of perioperative complications in spinal surgery. However, those studies evaluated fragmentary variables such as diabetes, obesity, and surgical methods [ 9 , 10 , 14 , 4 ]. Acarbaş et al. have investigated preoperative PNI in 408 patients undergoing spinal surgery and found that PNI is a significant factor for predicting perioperative adverse events in multivariate analysis [ 2 ]. However, the prognostic impact of PNI in patients undergoing metastatic spinal surgery has not been reported yet. Interestingly, patients with radiculopathy alone without cord compressing lesion showed similar postoperative results in ambulatory function and complication incidence to those with myelopathy. The mechanism of cancer pain is unique and poorly established compared with neuropathic and inflammatory pain [ 6 ]. This difference might explain why patients in our study had extraordinary radicular pain which might reduce the ambulatory function such as myelopathy. In this perspective, we think that including myelopathy and radiculopathy is meaningful for studies about metastatic spinal diseases. Some limitations of this study should be acknowledged. Frist, this study had a small sample size and a retrospective design. For evaluating more variables in multivariate analysis, a larger sample size is required. In addition, precise muscle power evaluation was insufficient for analysis. Second, although this was a single institute study, there might be differences in surgical technique and/or indications among three surgeons. Conclusions In surgical treatment for MST with neurologic symptoms, the recovery of postoperative ambulatory function might be predicted by assessing patient’s sarcopenia component. Moreover, quantitative evaluation of nutritional status can be a cornerstone for preventing perioperative complications. It is believed that these factors need to be considered by surgeons when deciding surgical treatment for MST to enhance functional outcome and improve safety for patients. Declarations Funding: No funding was received to assist with the preparation of this manuscript. Conflict of Interest: The authors declare that they have no conflict of interest. Availability of data and material: All data and code generated or analysed during this study are included in this published article [and its supplementary information files]. Code availability: All data and code generated or analysed during this study are included in this published article [and its supplementary information files]. Authors' contributions : All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Chungwon Bang. The first draft of the manuscript was written by Chungwon Bang and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval : Ethical approval was waived by the local Ethics Committee of , Seoul St. Mary’s Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care. Consent to participate : Informed consent was obtained from all individual participants included in the study. Consent for publication : The participant has consented to the submission of the case report to the journal. Acknowledgment: The author declares that he has no relevant or material financial interests that relate to the research described in this paper. 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Cite Share Download PDF Status: Published Journal Publication published 23 Oct, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Revision requested 08 Sep, 2024 Reviews received at journal 03 Sep, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviews received at journal 20 Jun, 2024 Reviewers agreed at journal 13 Jun, 2024 Reviewers agreed at journal 30 May, 2024 Reviewers invited by journal 30 May, 2024 Editor assigned by journal 29 May, 2024 Submission checks completed at journal 29 May, 2024 First submitted to journal 27 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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of","correspondingAuthor":false,"prefix":"","firstName":"Myung-Sup","middleName":"","lastName":"Ko","suffix":""},{"id":312865146,"identity":"eb32f66a-d48c-4ec5-bf84-b678eb7cbd43","order_by":2,"name":"Young-Il Ko","email":"","orcid":"","institution":"The Catholic University of Korea, Korea, Republic of","correspondingAuthor":false,"prefix":"","firstName":"Young-Il","middleName":"","lastName":"Ko","suffix":""},{"id":312865147,"identity":"c7c4ecae-d48b-4cf7-b79c-49c9c70cad9b","order_by":3,"name":"Young-Hoon Kim","email":"","orcid":"","institution":"The Catholic University of Korea, Korea, Republic of","correspondingAuthor":false,"prefix":"","firstName":"Young-Hoon","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-05-28 03:51:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4487908/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4487908/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00701-024-06288-4","type":"published","date":"2024-10-23T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58315473,"identity":"1d9b25e3-f967-4b67-86fb-bb8b473ff797","added_by":"auto","created_at":"2024-06-13 20:57:25","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25785,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/bf748e741c36fe71ed55384f.jpg"},{"id":58316050,"identity":"641e14ac-c64a-4317-85f1-5720dc17cb58","added_by":"auto","created_at":"2024-06-13 21:05:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21289,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/a496488c1d9a7285c078a303.jpg"},{"id":58314639,"identity":"e531ad9a-3e68-42bf-a649-cbda120d6196","added_by":"auto","created_at":"2024-06-13 20:49:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18401,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/11b57ed65152fba266c58b41.jpg"},{"id":58316986,"identity":"0ab94cfb-fdba-49ba-984b-7043318ab4d3","added_by":"auto","created_at":"2024-06-13 21:13:25","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":18494,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/53b7ea227c0aab3315bb3840.jpg"},{"id":58314640,"identity":"807c33ee-b0fb-49e1-a261-eabfa0b76541","added_by":"auto","created_at":"2024-06-13 20:49:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":106145,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/e065434159ddf7b4be789bc6.jpg"},{"id":67681875,"identity":"928ec936-ace9-46cd-a986-5b7adec03250","added_by":"auto","created_at":"2024-10-28 16:10:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":708982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4487908/v1/4c8546c3-5149-4fb5-aa21-33d943552580.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Sarcopenia and Nutritional Status on Surgical Outcomes for Metastatic Spinal Tumors : In the Perspective of Peri-operative Complications and Performance Improvement","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLife expectancy and quality of life of patients with cancer are improving due to effective managements. For solid tumors, clinical incidence of spinal metastases is about 15% and surgical treatments for metastatic spinal tumor (MST) are increasing and prognosis of such patients is more important than before [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several studies about prognostic factors in surgical treatment for MST. Majority of these studies were focused on cord compressing metastatic lesion and analyzed outcomes were mostly ambulatory functions after surgery. Preoperative ambulation is the most important prognostic factor based on results of several [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSarcopenia and nutritional factor have been emphasized for better functional outcomes after surgery in several studies recently [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Thus, we assessed sarcopenia and nutritional factor in the present study. It has been reported that postoperative complications are more frequent and critical in prognosis of MST patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, we also investigated prognostic factors for perioperative complications.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was approved by the institutional review board, which waived the requirement for participant informed consent owing to the retrospective nature of the study (No. 2024-1177-0001). A total of 112 MST cases were surgically treated at our institute between November 2016 and December 2022. Surgical indications were severe painful symptoms with MST whose general condition were candidate for spinal surgery. Patients with axial pain only and simple decompression or fixation surgery were excluded. The general aim of surgery was to decompress neural compressing lesions and/or reconstruct the spinal alignment for stability by anterior or posterior or anteroposterior approaches. Of 112 cases, 37 cases had no neurologic symptoms but only axial pain related to mechanical instability. Thus, they were excluded from this study. Four patients had two surgeries and one patient had three surgeries in another level which was not considered as recurrence in the surgical level. Finally, 75 cases in 69 patients were included in this study.\u003c/p\u003e \u003cp\u003eInformation investigated in this study included demographics, length of stay in hospital (LoS), locations, primary tumor, the 5-item modified frailty index (mFI-5), Charlson Comorbidity Index (CCI), time interval between symptom onset and surgery (TIS), decompressed level, perioperative Eastern Cooperative Oncology Group performance status [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], perioperative Nurick grade, prognostic nutritional index (PNI), spinal instability neoplastic score (SINS), epidural spinal cord compression (ESCC) scale, psoas muscle index (PMI), intensive care unit (ICU) stay, and postoperative complications.\u003c/p\u003e \u003cp\u003ePostoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. ECOG scale rather than Nurick grade system was used since Nurick grade was for cord compression disease [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and we defined the improvement of ambulatory function as improvement in ECOG scale. For complications, we applied complication classification system for orthopaedic surgery [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient\u0026rsquo;s admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax.\u003c/p\u003e \u003cp\u003eFor all statistical analyses, SPSS 24.00 software was used. Univariate and multivariate analyses were done. Median value was used as a cut off. Variables associated with postoperative ambulatory functions and complications were determined as a significant prognostic factor in univariate analysis (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.2). Logistic regression was then performed for prognostic factor analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe average age of patients analyzed in this study was 61.8 years (range, 26\u0026ndash;83 years). Most (62.6%) patients were females. The mean LoS was 21 days (range, 4\u0026ndash;74 days). Mean ICU stay was 0.53 days (range, 0\u0026ndash;5 days). The most common sites of primary tumor and spinal location of spinal tumor were lung (30.6%) and thorax (41.3%), respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ePatients characteristics\u003c/b\u003e LoS, length of stay in hospital; ICU, intensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.8 (26\u0026ndash;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyears (range)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (4\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edays (range)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.53 (0\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003edays (range)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSite of primary tumors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"12\" rowspan=\"13\"\u003e \u003cp\u003ecases (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (30.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyeloma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatobilliary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThyroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLocation of spinal tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ecases (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCervical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (41.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative change was evaluated by Nurick grade and ECOG performance status. Nurick grade was improved in 50% of cases postoperatively. However, 48% of cases were unchanged (Fig.\u0026nbsp;1). Similarly, ECOG performance status was improved in 41% of cases whereas 57% of cases were unchanged (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eChange of postopertive ambulatory function\u003c/b\u003e ECOG, Eastern Cooperative Oncology Group performance status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurick grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (56.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (50.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorsened\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients were divided into myelopathy and radiculopathy alone groups. Their postoperative ambulation and complications were then investigated. Both postoperative ambulation and complications showed no significant difference in distribution between the two groups (Figs.\u0026nbsp;3, 4).\u003c/p\u003e \u003cp\u003eIn univariate analysis, significant prognostic factors for improvement of postoperative ambulation and occurrence of perioperative complications were investigated respectively. For logistic regression, we divided variables into two groups based on their median values. Tumor location was divided into cord level or not.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative ambulation\u003c/h2\u003e \u003cp\u003emFI-5, preoperative ECOG status, preoperative Nurick grade, ESCC, and PMI were associated with improvement of postoperative ambulation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.2) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among those factors, we excluded Nurick grade which showed the same result as ECOG status to enhance the statistical power of multivariate regression analysis. In multivariate analysis, preoperative ECOG (RR: 6.699; 95% CI: 1.907\u0026ndash;23.538, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) and PMI (RR: 4.741; 95% CI: 1.369\u0026ndash;16.427, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014) were found to be significantly associated with postoperative ambulation (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eUnivariate association with the postoperative ambulation\u003c/b\u003e CI, confidence interval; mFI-5, 5-item modified frailty index; CCI, Charlson Comorbidity Index; TIS, time interval between symptom onset and surgery; ECOG, Eastern Cooperative Oncology Group performance status; PNI, prognostic nutritional index; SINS, spinal instability neoplastic score; ESCC, epidural spinal cord compression; PMI, psoas muscle index\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.276\u0026ndash;1.704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.679\u0026ndash;4.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of spinal tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.672\u0026ndash;4.372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.133\u0026ndash;1.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.582\u0026ndash;3.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.725\u0026ndash;4.529\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecompressed level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.416\u0026ndash;2.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative ECOG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.377\u0026ndash;9.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Nurick\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.377\u0026ndash;9.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.384\u0026ndash;2.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.912\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSINS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.592\u0026ndash;3.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.084\u0026ndash;1.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.853\u0026ndash;5.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMultivariate analysis with the postoperative ambulation\u003c/b\u003e CI, confidence interval; ECOG, Eastern Cooperative Oncology Group performance status; ESCC, epidural spinal cord compression; PMI, psoas muscle index\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultivariate relative risk (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative ECOG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.699 (1.907\u0026ndash;23.538)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.266 (0.064\u0026ndash;1.096)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.741 (1.369\u0026ndash;16.427)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative medical complications\u003c/h2\u003e \u003cp\u003eA total of 15 (20.0%) cases had confirmed medical complications. Three cases expired. There were the most severe complications (Fig.\u0026nbsp;5). In univariate analysis, mFI-5 and PNI were associated with perioperative complication (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.2) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In multivariate analysis, PNI (RR: 0.278; 95% CI: 0.079\u0026ndash;0.974, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) was found to be significantly associated with perioperative complications (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eUnivariate association with the perioperative medical complications\u003c/b\u003e CI, confidence interval; mFI-5, 5-item modified frailty index; CCI, Charlson Comorbidity Index; TIS, time interval between symptom onset and surgery; ECOG, Eastern Cooperative Oncology Group performance status; PNI, prognostic nutritional index; SINS, spinal instability neoplastic score; ESCC, epidural spinal cord compression; PMI, psoas muscle index\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.282\u0026ndash;2.718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.817\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.377\u0026ndash;4.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.720\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of spinal tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.318\u0026ndash;3.174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emFI-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.725\u0026ndash;8.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.580\u0026ndash;5.798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTIS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.263\u0026ndash;2.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecompressed level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.368\u0026ndash;3.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.816\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative ECOG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.263\u0026ndash;2.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Nurick\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.263\u0026ndash;2.543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.079\u0026ndash;0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSINS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.322\u0026ndash;3.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.216\u0026ndash;3.730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.406\u0026ndash;3.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.681\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis with the perioperative medical complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultivariate relative risk (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.278 (0.079\u0026ndash;0.974)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eCI, confidence interval; PNI, prognostic nutritional index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study on 75 cases of surgical treatment for metastatic spinal tumor with neurologic symptoms had two major findings. Frist, improvement of postoperative ambulatory functions were associated with preoperative PMI. Second, perioperative complications were associated with preoperative PNI. Even though these results were not different from previous studies, there were some differences in the present study. Most study of prognostic factor analysis in metastatic spinal tumor were associated with cord lesion [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, as radiculopathy with severe pain could reduce ambulatory function, we decided to investigate all patients with neurologic symptoms. In terms of prognostic factors, we analyzed PMI for psoas muscle and PNI for nutritional factor which were found to be beneficial in spine surgeries [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and also in MST, status of psoas muscle and nutrition is important for improvement of ambulatory function and prevention of perioperative complications.\u003c/p\u003e \u003cp\u003eIn the present study, mFI-5 was associated with both postoperative ambulation and complications with relative significance in univariate analysis, similar to previous studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, mFI-5 was not a significant prognostic factor for postoperative ambulation or complications in multivariate analysis, different from PMI and PNI. Because PMI and PNI are more objective data than mFI-5, those variables could reduce the recall bias. They were confirmed to be more significant prognostic factors in multivariate analysis.\u003c/p\u003e \u003cp\u003eMost studies have revealed that preoperative ambulation is the most significant prognostic factor for postoperative ambulatory function [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], similar to results of the present study. Most studies have grouped ambulatory functions using a binary method such as ambulatory or not. However, natural course of neurologic recovery is ambiguous. Adequate time for recovery is especially hard to be defined well [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, more precise and quantitative assessments for ambulatory function to find out a subtle improvement could be meaningful not only for ambulatory function itself, but also for potential neurologic recovery in the future.\u003c/p\u003e \u003cp\u003ePrevious studies have reported several clinical and laboratory predictors of perioperative complications in spinal surgery. However, those studies evaluated fragmentary variables such as diabetes, obesity, and surgical methods [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Acarbaş et al. have investigated preoperative PNI in 408 patients undergoing spinal surgery and found that PNI is a significant factor for predicting perioperative adverse events in multivariate analysis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, the prognostic impact of PNI in patients undergoing metastatic spinal surgery has not been reported yet.\u003c/p\u003e \u003cp\u003eInterestingly, patients with radiculopathy alone without cord compressing lesion showed similar postoperative results in ambulatory function and complication incidence to those with myelopathy. The mechanism of cancer pain is unique and poorly established compared with neuropathic and inflammatory pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This difference might explain why patients in our study had extraordinary radicular pain which might reduce the ambulatory function such as myelopathy. In this perspective, we think that including myelopathy and radiculopathy is meaningful for studies about metastatic spinal diseases.\u003c/p\u003e \u003cp\u003eSome limitations of this study should be acknowledged. Frist, this study had a small sample size and a retrospective design. For evaluating more variables in multivariate analysis, a larger sample size is required. In addition, precise muscle power evaluation was insufficient for analysis. Second, although this was a single institute study, there might be differences in surgical technique and/or indications among three surgeons.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn surgical treatment for MST with neurologic symptoms, the recovery of postoperative ambulatory function might be predicted by assessing patient\u0026rsquo;s sarcopenia component. Moreover, quantitative evaluation of nutritional status can be a cornerstone for preventing perioperative complications. It is believed that these factors need to be considered by surgeons when deciding surgical treatment for MST to enhance functional outcome and improve safety for patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: No funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eConflict of Interest:\u0026nbsp;The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material: All data and code generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003eCode availability: All data and code generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions : All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Chungwon Bang. The first draft of the manuscript was written by Chungwon Bang and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eEthics approval : Ethical approval was waived by the local Ethics Committee of , Seoul St. Mary\u0026rsquo;s Hospital\u0026nbsp;in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.\u003c/p\u003e\n\u003cp\u003eConsent to participate : Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication : The participant has consented to the submission of the case report to the journal.\u003c/p\u003e\n\u003cp\u003eAcknowledgment: The author declares that he has no relevant or material financial interests that relate to the research described in this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAcarbaş A (2019) A Novel Prognostic Marker in Patients Undergoing Spinal Surgery: Prognostic Nutritional Index. 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Clin Respir J 15:225\u0026ndash;231. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/crj.13288\u003c/span\u003e\u003cspan address=\"10.1111/crj.13288\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Metastasis, Spine, Complications, Nutritional status, Sarcopenia","lastPublishedDoi":"10.21203/rs.3.rs-4487908/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4487908/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWith the advancement of cancer treatment, appropriate treatment for musculoskeletal problems is becoming more important as it extends the patient's lifespan and improves the quality of life. In surgical treatment for metastatic spine tumors (MST), various efforts are being considered to obtain a good prognosis. The purposes of this study are to analyze prognostic factors for postoperative ambulation and perioperative complications in patients surgically treated for MST with neurologic symptoms.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSeventy five cases of patients who underwent surgery for MST with neurologic symptoms were enrolled between December 2016 and January 2023. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. We defined the improvement of ambulatory function as improvement in ECOG scale. For complications, we applied complication classification system for orthopaedic surgery. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient\u0026rsquo;s admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. Prognostic factors were collected and analyzed for relationship by logistic regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 75 cases, postoperatively 42 (56%) cases of patients were improved in Nurick grade, 36 (48%) cases of patients in ECOG performance. And 21 (28%) cases of patients were treated in ICU and 15 (20%) cases of patients suffered from major perioperative complications. Regression analysis showed that clinical factors such as ECOG, PMI and PNI were related to the improvement of ambulatory function and incidence of perioperative complications. On multivariate analysis, improvement of ambulatory function was associated with PMI (p\u0026thinsp;=\u0026thinsp;0.014) and incidence of perioperative complications was associated with PNI (p\u0026thinsp;=\u0026thinsp;0.045).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePreoperative nutritional status and sarcopenia are related factors in the outcome of surgical treatment for MST, and preoperative efforts to improve these may be a way to obtain better clinical results.\u003c/p\u003e","manuscriptTitle":"Effects of Sarcopenia and Nutritional Status on Surgical Outcomes for Metastatic Spinal Tumors : In the Perspective of Peri-operative Complications and Performance Improvement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 20:49:20","doi":"10.21203/rs.3.rs-4487908/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-08T09:25:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-03T19:46:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183008535690368349478401594060691459857","date":"2024-08-06T17:12:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-20T15:56:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62585236978710089208633735888530933129","date":"2024-06-13T11:34:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263691834269469714930885647105758804011","date":"2024-05-30T07:34:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-30T07:32:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-29T22:55:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-29T22:55:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2024-05-28T03:49:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1c07890c-e74c-40d1-aa94-795c9e6503cf","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:01:34+00:00","versionOfRecord":{"articleIdentity":"rs-4487908","link":"https://doi.org/10.1007/s00701-024-06288-4","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2024-10-23 15:57:30","publishedOnDateReadable":"October 23rd, 2024"},"versionCreatedAt":"2024-06-13 20:49:20","video":"","vorDoi":"10.1007/s00701-024-06288-4","vorDoiUrl":"https://doi.org/10.1007/s00701-024-06288-4","workflowStages":[]},"version":"v1","identity":"rs-4487908","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4487908","identity":"rs-4487908","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}