Background/Objectives: Metastatic spine disease (MSD) affects a significant proportion of patients with advanced malignancies and often necessitates surgical intervention to preserve neurological function, alleviate pain, and maintain spinal stability. While oncologic spine surgery is ideally performed in a planned, semi-elective setting, a substantial number of patients require unplanned (urgent or emergent) surgery due to acute deterioration. The impact of surgical planning status on postoperative outcomes following metastatic spine tumor surgery remains underexplored. This study aimed to compare the patient characteristics and short-term outcomes of those undergoing planned versus unplanned surgery for spinal metastases. Methods: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2018 to 2023. Patients with disseminated cancer undergoing tumor surgery were identified. Case types were grouped into planned (elective) and unplanned (urgent or emergent). The primary endpoint was failure to rescue (FTR); secondary endpoints included 30-day major complications, 30-day mortality, and length of hospital stay. Univariable and multivariable regression analyses were performed. Results: A total of 2147 patients met our inclusion criteria, out of whom 60% (n = 1284) underwent planned and 40% (n = 863) underwent unplanned surgery. Patients in the unplanned surgery group had a significantly higher prevalence of severe hypoalbuminemia, severe anemia, and ASA class IV status (p ≤ 0.001 for all). For our primary endpoint, a multivariable analysis showed a significant association between unplanned surgery and FTR (OR 2.11 [95% CI 1.24 to 3.56]; p = 0.005). Significant associations were also found with 30-day mortality (OR 1.84 [95% CI 1.25 to 2.72]; p = 0.002) and length of hospital stay (β 2.7 [95% CI 1.97 to 3.43]; p < 0.001). However, unplanned surgery could not independently predict 30-day major complications (OR 1.21 [95% CI 0.97 to 1.51]; p = 0.08). Conclusions: Our study found that unplanned surgery for spinal metastases was associated with significantly higher rates of FTR, 30-day mortality, and extended hospital stay, independent of other covariates. These findings highlight the importance of the timely identification of patients requiring surgery and the potential benefits of semi-elective care.

Background: Performance status is often cited as an independent predictor of survival after metastatic spine tumor surgery (MSTS), but its standalone predictive value for short-term outcomes remains unclear. We aimed to evaluate how well Karnofsky (KPS) and Eastern Cooperative Oncology Group performance status (ECOG-PS) predict 90-day survival, a common surgical candidacy threshold, in patients managed with MSTS. Methods: We conducted a retrospective study of 175 adult patients who underwent MSTS at a single institution (2012–2025). All patients had documented preoperative KPS and ECOG-PS scores. Univariable logistic regression was used to assess associations with 90-day survival. Predictive performance was assessed by discrimination (AUC), diagnostic accuracy, calibration (Brier score), and clinical utility (decision curve analysis). Results: The crude 90-day survival rate was 73%. Both KPS (OR 1.02 [95% CI 1.01 to 1.05]; p = 0.001) and ECOG-PS (OR 0.51 [95% CI 0.36 to 0.73]; p < 0.001) were statistically associated with survival. However, discrimination was modest (AUC 0.65 for KPS, 0.68 for ECOG-PS), with the most balanced diagnostic accuracy achieved at KPS ≥ 70 (sensitivity 0.66, specificity 0.62) and ECOG-PS ≤ 2 (sensitivity 0.76, specificity 0.5). Calibration was fair (Brier scores 0.185 and 0.182, respectively). Decision curve analysis showed minimal net benefit across most threshold probabilities, with ECOG-PS performing slightly better at intermediate thresholds (30–60%), the zone of greatest clinical uncertainty. Conclusions: Despite being widely cited as an independent predictor of postoperative survival in patients with metastatic spine disease, performance status assessed via the KPS and ECOG-PS demonstrated only modest overall discriminatory ability, diagnostic accuracy, calibration, and clinical utility when used alone to predict 90-day survival after MSTS. While both scores retained meaningful value at the extremes (i.e., patients with very poor or very good performance status had more predictable outcomes), caution is warranted in intermediate cases, where performance status alone may be insufficient to guide treatment decisions. These findings highlight the critical difference between statistical association and the real-world clinical utility of a single metric to predict outcome in this patient population.

Purpose: Instrumentation failure (IF) is a major complication after lumbar spondylectomy for spinal tumors, yet risk factors remain poorly defined. The present study aimed to determine the prevalence of IF and identify variables associated with IF and revision surgery using pooled individual patient data. Methods: A systematic review and individual patient data analysis were performed per PRISMA guidelines. PubMed, CDSR, and Epistemonikos were searched through January 2025, and additional patient-level data were obtained from prior series. Studies were included if they reported outcomes after lumbar spondylectomy for primary or metastatic tumors. Demographic, tumor, surgical, and (neo)adjuvant therapy variables were extracted. Statistical analyses included chi-square tests, t-tests, and Firth’s penalized logistic regression. Variables with p < 0.1 on univariable analysis and considered clinically relevant were entered into a penalized multivariable model, with a sensitivity analysis incorporating estimated blood loss as a surrogate of operative burden. Results: A total of 169 patients (mean age 40.7 ± 17.6 years) were included after screening. IF occurred in 14% (23/169) of patients, with 96% of those requiring revision. On univariable regression, risk factors for IF included combined approach (OR 4.72, p = 0.01), staged procedures (OR 5.51, p < 0.001), pelvic fixation (OR 5.17, p < 0.001), multilevel spondylectomy (OR 2.74, p = 0.036), longer operative time (OR 1.17 per hour, p = 0.001), and greater blood loss (OR 1.16 per liter, p = 0.034). On primary multivariable analysis incorporating clinically relevant variables, no variable retained statistical significance, although pelvic fixation demonstrated the strongest trend (OR 2.19, p = 0.12). On sensitivity analysis adjusting for operative burden, pelvic fixation was significantly associated with IF (OR 4.95, p = 0.043). Median time to IF was 27 months. Conclusion: IF after lumbar spondylectomy occurs in roughly one in seven patients and is associated with multiple markers of procedural complexity. Although no single independent predictor was identified in the primary multivariable analysis, pelvic fixation demonstrated the strongest association across models, likely reflecting the increased biomechanical demands of lumbosacral constructs. Careful planning, reinforcement strategies, and long-term follow-up are critical to mitigate failure risk.