{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T10:49:50Z","timestamp":1785408590238,"version":"3.56.0"},"reference-count":49,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T00:00:00Z","timestamp":1781308800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Ministry of Health National Medical Research Council, Singapore","award":["MOH-001924"],"award-info":[{"award-number":["MOH-001924"]}]},{"name":"Ministry of Health National Medical Research Council, Singapore","award":["CIAINV25jan-0005"],"award-info":[{"award-number":["CIAINV25jan-0005"]}]},{"award":["MOH-001924"],"award-info":[{"award-number":["MOH-001924"]}],"id":[{"id":"https:\/\/ror.org\/04x3cxs03","id-type":"ROR","asserted-by":"publisher"}]},{"award":["CIAINV25jan-0005"],"award-info":[{"award-number":["CIAINV25jan-0005"]}],"id":[{"id":"https:\/\/ror.org\/04x3cxs03","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background\/Objectives: Although the Spinal Instability Neoplastic Score (SINS) is widely used to estimate spinal metastases fracture risk and guide decisions on stabilisation procedures, prior studies have demonstrated mixed results. Patients with the same score exhibit clinically heterogeneous outcomes, with some SINS criteria correlating less well with the estimated fracture risk than others. There are also barriers to implementation such as the time burden required for manual calculation and interobserver variability associated with qualitative morphological criteria. SINS also lacks sensitivity for detecting latent structural compromise in treatment-naive patients and those susceptible to the iatrogenic effects of stereotactic body radiation therapy. This review aims to evaluate emerging imaging, biomechanical, and microstructural markers with the potential to improve fracture risk stratification and prognostication for spinal oncology patients. Methods: We synthesise evidence across three innovative frontiers: (1) biomechanical modelling, including CT-derived finite element analysis and failure-load pattern models; (2) radiomics, utilizing radiomics features from radiological imaging to develop a predictive model; and (3) microstructural MRI biomarkers, exploring the translatability of the Vertebral Bone Quality score, fat fraction, and paraspinal muscle atrophy from osteoporosis to the metastatic spine. Results: Emerging biomechanical, radiomic and microstructural imaging markers show potential in addressing some limitations of traditional SINS criteria for fracture risk stratification across the spinal oncology treatment continuum, from initial diagnosis to post-radiation surveillance, thereby facilitating more precise risk assessment. However, current evidence remains largely retrospective and heterogeneous, and further validation is required before clinical adoption. Conclusions: We propose a framework that shifts the paradigm from conventional morphological scoring toward a multiparametric assessment of spinal stability.<\/jats:p>","DOI":"10.3390\/diagnostics16121835","type":"journal-article","created":{"date-parts":[[2026,6,15]],"date-time":"2026-06-15T00:44:58Z","timestamp":1781484298000},"page":"1835","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond SINS: A Critical Review of Biomechanical, Microstructural, and Radiomic Biomarkers for Predicting Fracture Risk in Spinal Metastases"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4503-3725","authenticated-orcid":false,"given":"An Sen","family":"Tan","sequence":"first","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2031-4106","authenticated-orcid":false,"given":"Calvin Kai En","family":"Tjio","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan Jiong Hao","family":"Tan","sequence":"additional","affiliation":[{"name":"National University Spine Institute, Department of Orthopaedic Surgery, National University Hospital, 1E Lower Kent Ridge Road, Singapore 119228, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4538-5031","authenticated-orcid":false,"given":"Naresh","family":"Kumar","sequence":"additional","affiliation":[{"name":"National University Spine Institute, Department of Orthopaedic Surgery, National University Hospital, 1E Lower Kent Ridge Road, Singapore 119228, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0262-3802","authenticated-orcid":false,"given":"Wilson","family":"Ong","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4928-1195","authenticated-orcid":false,"given":"Shuliang","family":"Ge","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1544-1250","authenticated-orcid":false,"given":"Yi Liang","family":"Tan","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7986-3495","authenticated-orcid":false,"given":"Eric","family":"Fang","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Balamurugan A.","family":"Vellayappan","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0082-9033","authenticated-orcid":false,"given":"James Thomas Patrick Decourcy","family":"Hallinan","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore"},{"name":"Department of Diagnostic Radiology, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Serratrice, N., Faddoul, J., Tarabay, B., Attieh, C., Chalah, M.A., Ayache, S.S., and Abi Lahoud, G.N. 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