{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T22:37:59Z","timestamp":1782772679772,"version":"3.54.5"},"reference-count":52,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,9,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Spinal stereotactic radiosurgery (SSRS) is an established treatment modality for spinal metastatic disease. A common complication of SSRS is postradiation pathologic fracture. The authors evaluated the risk of pathologic fracture in sacral SSRS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>All patients receiving SSRS in 1 to 5 fractions to 1 or more sacral levels between 2011 and 2020 at participating institutions were included. Demographic, histological, anatomical, and outcome data were obtained from electronic medical records. Data were analyzed using SPSS version 28.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>Of 67 total patients, 50 (74.6%) were men and 17 (25.4%) were women. The most common tumor histologies were prostate adenocarcinoma (n = 16 [23.9%]) and renal cell carcinoma (n = 12 [17.9%]). Median (range) age at treatment was 63 (8\u201387) years. The mean \u00b1 SD (range) number of levels treated was 1.5 \u00b1 0.7 (1\u20134) levels. Mean \u00b1 SD (range) bone density at S1 was 208.0 \u00b1 74.4 (\u22123.0 to 443.3) Hounsfield units (HUs). Median (range) follow-up was 16.6 (1.5\u2013132) months, median \u00b1 SD (range) overall survival was 24 \u00b1 21.0 (1.7\u201383.3) months, and the 1-year local control rate was 83.6%. Fourteen patients (20.9%) experienced fracture within the radiation field. There was no association between fracture and patient sex (p = 0.32), age (p = 0.40), S1 HU (p = 0.28), tumor location according to Denis classification (p = 0.87), presence of pain (p = 0.66), single versus multifraction radiation (p = 0.44), or number of levels treated (p = 0.52). Patients experiencing in-field progression were more likely to experience fracture (61.5% vs 10.2%, p &lt; 0.001), and patients experiencing fracture had a higher average Spine Instability Neoplastic Score than patients without fracture (5.7 vs 4.3, p = 0.049). Only local control remained as a factor associated with sacral fracture in the multivariate analysis. Of the patients experiencing fracture, 10 (71.4%) were symptomatic and 3 of those (30.0%) underwent post-SSRS surgical intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>Pathologic fracture may occur after sacral SSRS in a significant number of patients and is significantly associated with failure of local control.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2025.2.spine24770","type":"journal-article","created":{"date-parts":[[2025,6,20]],"date-time":"2025-06-20T21:16:50Z","timestamp":1750454210000},"page":"305-312","source":"Crossref","is-referenced-by-count":2,"title":["Sacral fracture risk after stereotactic spinal radiosurgery: a multi-institution, retrospective analysis"],"prefix":"10.3171","volume":"43","author":[{"given":"Eric A.","family":"Goethe","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Baylor College of Medicine, Houston;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Romulo A.","family":"Andrade de Almeida","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco","family":"Call-Orellana","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony L.","family":"Mikula","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle J.","family":"Clarke","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth W.","family":"Merrell","sequence":"additional","affiliation":[{"name":"Radiation Oncology, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter S.","family":"Rose","sequence":"additional","affiliation":[{"name":"Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S. Mohammed","family":"Karim","sequence":"additional","affiliation":[{"name":"Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph R.","family":"Linzey","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas J.","family":"Szerlip","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Behrang","family":"Amini","sequence":"additional","affiliation":[{"name":"Radiology, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas H.","family":"Beckham","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amol J.","family":"Ghia","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jing","family":"Li","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin C.","family":"Tom","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary Frances","family":"McAleer","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Subha","family":"Perni","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chenyang","family":"Wang","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Debra N.","family":"Yeboa","sequence":"additional","affiliation":[{"name":"Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony","family":"Price","sequence":"additional","affiliation":[{"name":"John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Alvarez-Breckenridge","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurence D.","family":"Rhines","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudio E.","family":"Tatsui","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert Y.","family":"North","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery,"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Handb Clin Neurol","first-page":"227","article-title":"Epidural and intramedullary spinal metastasis: clinical features and role of fractionated radiotherapy","volume":"149","author":"Rades D","year":"2018","unstructured":"Rades D, Schiff D. Epidural and intramedullary spinal metastasis: clinical features and role of fractionated radiotherapy. Handb Clin Neurol. 2018;149:227\u2013238."},{"issue":"3","key":"b2","series-title":"J Radiosurg SBRT","first-page":"237","article-title":"International survey of the treatment of metastatic spinal cord compression","volume":"3","author":"Ryu S","year":"2015","unstructured":"Ryu S, Maranzano E, Schild SE,  International survey of the treatment of metastatic spinal cord compression. 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J Clin Oncol. 2016;34(6):597\u2013602."},{"issue":"3","key":"b4","series-title":"Neurosurgery","first-page":"314","article-title":"Vertebral compression fracture after spine stereotactic body radiation therapy: a review of the pathophysiology and risk factors","volume":"83","author":"Faruqi S","year":"2018","unstructured":"Faruqi S, Tseng CL, Whyne C,  Vertebral compression fracture after spine stereotactic body radiation therapy: a review of the pathophysiology and risk factors. Neurosurgery. 2018;83(3):314\u2013322."},{"issue":"7","key":"b5","series-title":"Lancet Oncol","first-page":"1023","article-title":"Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2\/3 trial","volume":"22","author":"Sahgal A","year":"2021","unstructured":"Sahgal A, Myrehaug SD, Siva S,  Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2\/3 trial. 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JAMA Oncol. 2020;6(4):567\u2013577."},{"issue":"27","key":"b8","series-title":"J Clin Oncol","first-page":"3426","article-title":"Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score","volume":"31","author":"Sahgal A","year":"2013","unstructured":"Sahgal A, Atenafu EG, Chao S,  Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score. J Clin Oncol. 2013;31(27):3426\u20133431."},{"key":"b9","series-title":"Technol Cancer Res Treat","first-page":"1533033820945798","article-title":"Conventional radiotherapy and stereotactic radiosurgery in the management of metastatic spine disease","volume":"19","author":"Zhang HR","year":"2020","unstructured":"Zhang HR, Li JK, Yang XG, Qiao RQ, Hu YC. 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J Radiosurg SBRT. 2014;3(1):59\u201365."},{"issue":"3","key":"b17","series-title":"Korean J Spine","first-page":"103","article-title":"Evaluation of risk factors for vertebral compression fracture after stereotactic radiosurgery in spinal tumor patients","volume":"11","author":"Sung SH","year":"2014","unstructured":"Sung SH, Chang UK. Evaluation of risk factors for vertebral compression fracture after stereotactic radiosurgery in spinal tumor patients. Korean J Spine. 2014;11(3):103\u2013108."},{"key":"b18","series-title":"World Neurosurg","first-page":"548","article-title":"Development of a Metastatic Spinal Tumor Frailty Index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery","volume":"95","author":"De la Garza Ramos R","year":"2016","unstructured":"De la Garza Ramos R, Goodwin CR, Jain A,  Development of a Metastatic Spinal Tumor Frailty Index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery. 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Neurosurgery. 2018;83(3):314\u2013322."},{"issue":"7","key":"b5","series-title":"Lancet Oncol","first-page":"1023","article-title":"Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2\/3 trial","volume":"22","author":"Sahgal A","year":"2021","unstructured":"Sahgal A, Myrehaug SD, Siva S,  Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases: an open-label, multicentre, randomised, controlled, phase 2\/3 trial. Lancet Oncol. 2021;22(7):1023\u20131033."},{"issue":"5","key":"b6","series-title":"J Neurosurg Spine","first-page":"430","article-title":"Radiation-induced vertebral compression fracture following spine stereotactic radiosurgery: clinicopathological correlation","volume":"18","author":"Al-Omair A","year":"2013","unstructured":"Al-Omair A, Smith R, Kiehl TR,  Radiation-induced vertebral compression fracture following spine stereotactic radiosurgery: clinicopathological correlation. J Neurosurg Spine. 2013;18(5):430\u2013435."},{"issue":"4","key":"b7","series-title":"JAMA Oncol","first-page":"567","article-title":"Stereotactic ablative radiotherapy for the management of spinal metastases: a review","volume":"6","author":"Glicksman RM","year":"2020","unstructured":"Glicksman RM, Tjong MC, Neves-Junior WFP,  Stereotactic ablative radiotherapy for the management of spinal metastases: a review. JAMA Oncol. 2020;6(4):567\u2013577."},{"issue":"27","key":"b8","series-title":"J Clin Oncol","first-page":"3426","article-title":"Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score","volume":"31","author":"Sahgal A","year":"2013","unstructured":"Sahgal A, Atenafu EG, Chao S,  Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score. J Clin Oncol. 2013;31(27):3426\u20133431."},{"key":"b9","series-title":"Technol Cancer Res Treat","first-page":"1533033820945798","article-title":"Conventional radiotherapy and stereotactic radiosurgery in the management of metastatic spine disease","volume":"19","author":"Zhang HR","year":"2020","unstructured":"Zhang HR, Li JK, Yang XG, Qiao RQ, Hu YC. Conventional radiotherapy and stereotactic radiosurgery in the management of metastatic spine disease. Technol Cancer Res Treat. 2020;19:1533033820945798."},{"issue":"1","key":"b10","series-title":"Int J Radiat Oncol Biol Phys","first-page":"83","article-title":"A phase 2 clinical trial of SABR followed by immediate vertebroplasty for spine metastases","volume":"104","author":"Wardak Z","year":"2019","unstructured":"Wardak Z, Bland R, Ahn C,  A phase 2 clinical trial of SABR followed by immediate vertebroplasty for spine metastases. Int J Radiat Oncol Biol Phys. 2019;104(1):83\u201389."},{"issue":"3","key":"b11","series-title":"J Neurooncol","first-page":"509","article-title":"Can the spinal instability neoplastic score prior to spinal radiosurgery predict compression fractures following stereotactic spinal radiosurgery for metastatic spinal tumor? 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Front Oncol. 2022;12:802595."},{"issue":"1","key":"b13","series-title":"Adv Radiat Oncol","first-page":"20","article-title":"Stereotactic spinal radiosurgery and delayed vertebral fracture risk","volume":"4","author":"Evans JD","year":"2018","unstructured":"Evans JD, Brown PD, Olivier KR. Stereotactic spinal radiosurgery and delayed vertebral fracture risk. Adv Radiat Oncol. 2018;4(1):20\u201325."},{"issue":"6","key":"b14","series-title":"J Neurosurg Spine","first-page":"928","article-title":"Vertebral compression fractures after stereotactic body radiation therapy: a large, multi-institutional, multinational evaluation","volume":"24","author":"Jawad MS","year":"2016","unstructured":"Jawad MS, Fahim DK, Gerszten PC,  Vertebral compression fractures after stereotactic body radiation therapy: a large, multi-institutional, multinational evaluation. 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