title: The Effect of Introducing the Spinal Instability Neoplastic Score in Routine Clinical Practice for Patients With Spinal Metastases.
abstract: BACKGROUND
  Stable spinal metastases are effectively treated with radiotherapy, whereas unstable spinal metastases often need surgical fixation followed by radiotherapy for local control. The Spinal Instability Neoplastic Score (SINS) was developed as a tool to assess spinal neoplastic related instability with the goal of helping to guide referrals among oncology specialists. We compare the average degree of spinal instability between patients with spinal metastases referred for surgery or for radiotherapy and evaluate whether this difference changed after introduction of the SINS in clinical practice.
  
  
  METHODS
  All patients with spinal metastases treated with palliative surgery or radiotherapy in the period 2009-2013 were identified in two spine centers. For all patients, the SINS was scored on pretreatment imaging. The SINS before and after introduction of the SINS in 2011 were compared within the surgical and radiotherapy group. Furthermore, the overall SINS was compared between the two groups.
  
  
  RESULTS
  The overall SINS was significantly higher in the surgical group, with a mean SINS of 10.7 (median 11) versus 7.2 (median 8) for the radiotherapy group. The mean SINS decreased significantly for both groups after introduction of the SINS in clinical practice from 11.2 to 10.3 in the surgical group and from 8.4 to 7.2 in the radiotherapy group.
  
  
  CONCLUSIONS
  The SINS differed significantly between patients treated with surgery or radiotherapy. The introduction of SINS led to a decrease in SINS score for both groups, suggesting that using SINS in metastatic spinal disease increases awareness for instability and may subsequently result in earlier referrals for surgical intervention.
  
  
  CONCLUSIONS
  Spinal metastases can present with varying degrees of mechanical instability. Because unstable spinal metastases may respond insufficiently to palliative radiotherapy and can lead to loss of ambulation, timely detection and appropriate referral are important. The Spinal Instability Neoplastic Score (SINS) may help physicians caring for patients with metastasized disease to identify spinal instability before the onset of neurological deficits. In this study, it was shown that the introduction of SINS in routine practice led to a decrease in spinal instability in radiotherapy and surgical cohorts. The use of SINS may increase awareness of instability and subsequently result in earlier referrals.
authors.affiliation: Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Anne L
authors.initials: AL
authors.lastname: Versteeg
authors.affiliation: Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Joanne M
authors.initials: JM
authors.lastname: van der Velden
authors.affiliation: Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Helena M
authors.initials: HM
authors.lastname: Verkooijen
authors.affiliation: Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Marco
authors.initials: M
authors.lastname: van Vulpen
authors.affiliation: Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: F Cumhur
authors.initials: FC
authors.lastname: Oner
authors.affiliation: Division of Spine, Department of Orthopedics, University of British Columbia, and the Combined Neurosurgical and Orthopedic Spine Program at Vancouver Coastal Health, Vancouver, British Columbia, Canada.
authors.forename: Charles G
authors.initials: CG
authors.lastname: Fisher
authors.affiliation: Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands J.J.Verlaan@umcutrecht.nl.
authors.forename: Jorrit-Jan
authors.initials: JJ
authors.lastname: Verlaan
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D010166:Palliative Care; D013125:Spinal Neoplasms / Q000473:pathology* / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery; D013131:Spine / Q000473:pathology* / Q000528:radiation effects
keywords: Cancer; Instability; Radiation oncology; Spinal metastases; Spinal neoplasms; Spine