• Mitchell S Fourman, Layla Siraj, Julia Duvall, Duncan C Ramsey, Rafael De La Garza Ramos, Muhamed Hadzipasic, Ian Connolly, Theresa Williamson, Ganesh M Shankar, Andrew Schoenfeld, Reza Yassari, Elie Massaad, and John H Shin.
• Departments of Orthopaedic Surgery and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York, USA.
• World Neurosurg. 2023 Jun 1; 174: e26e34e26-e34.

ObjectiveGroup patients who required open surgery for metastatic breast cancer to the spine by functional level and metastatic disease characteristics to identify factors that predispose to poor outcomes.MethodsA retrospective analysis included patients managed at 2 tertiary referral centers from 2008 to 2020. The primary outcome was a 90-day adverse event. A 2-step unsupervised cluster analysis stratified patients into cohorts using function at presentation, preoperative spine radiation, structural instability, epidural spinal cord compression (ESCC), neural deficits, and tumor location/hormone status. Comparisons were performed using χ2 test and one-way analysis of variance.ResultsFive patient "clusters" were identified. High function (HIGH) had thoracic metastases and an Eastern Cooperative Oncology Group (ECOG) score of 1.0 ± 0.8. Low function/irradiated (LOW + RADS) had preoperative radiation and the lowest Karnofsky scores (56.0 ± 10.6). Estrogen receptor or progesterone receptor (ER/PR) positive patients had >90% estrogen/progesterone positivity and moderate Karnofsky scores (74.0 ± 11.5). Lumbar/noncompressive (NON-COMP) had the fewest patients with ESCC grade 2 or 3 epidural disease (42.1%, P < 0.001). Low function/neurologic deficits (LOW + NEURO) had ESCC grade 2 or 3 disease and neurologic deficits. Adverse event rates were 25.0% in the HIGH group, 73.3% in LOW + RADS, 24.0% in ER/PR, 31.6% in NON-COMP, and 60.0% in LOW + NEURO (P = 0.003).ConclusionsFunction at presentation, tumor hormone signature, radiation history, and epidural compression delineated postoperative trajectory. We believe our results can aid in expectation management and the identification of at-risk patients who may merit closer surveillance following surgical intervention.Copyright © 2023 Elsevier Inc. All rights reserved.

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