{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T00:08:09Z","timestamp":1791245289665,"version":"4.1.0"},"reference-count":32,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,2,1]],"date-time":"2023-02-01T00:00:00Z","timestamp":1675209600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Open Access Publication Fund of the University of Freiburg"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Currently, there is uncertainty about the predictive factors for metastatic epidural spinal cord compression (MESCC) and consecutive symptomatology in tumor patients. Prognostic algorithms for identifying patients at risk for paralysis are missing. The influence of the pathologic fracture on the patient\u2019s symptoms is widely discussed in the literature and we hypothesize that pathologic fractures contribute to spinal cord compression and are therefore predictive of severe paralysis. We tested this hypothesis in 136 patients who underwent surgery for spinal metastases. The most common primary cancers were prostate (24.3%, n = 33), breast (11.0%, n = 15), lung (10.3%, n = 14), and cancer of unknown primary (10.3%, n = 14). MESCC primarily affected the thoracic (77.2%, n = 105), followed by the lumbar (13.2%, n = 18) and cervical (9.6%, n = 13) spine. Pathologic fractures occurred in 63.2% (n = 86) of patients, mainly in osteolytic metastases. On the American spinal injury association (ASIA) impairment scale (AIS), 63.2% (n = 86) of patients exhibited AIS grade D and 36.8% (n = 50) AIS grade C-A preoperatively. The presence of a pathologic fracture alone did not predict severe paralysis (AIS C-A, p = 0.583). However, the duration of sensorimotor impairments, patient age, spinal instability neoplastic score (SINS), and the epidural spinal cord compression (ESCC) grade together predicted severe paralysis (p = 0.006) as did the ESCC grade 3 alone (p = 0.028). This is in contrast to previous studies that stated no correlation between the degree of spinal cord compression and the severity of neurologic impairments. Furthermore, the high percentage of pathologic fractures found in this study is above previously reported incidences. The risk factors identified can help to predict the development of paralysis and assist in the improvement of follow-up algorithms and the timing of therapeutic interventions.<\/jats:p>","DOI":"10.3390\/jcm12031167","type":"journal-article","created":{"date-parts":[[2023,2,2]],"date-time":"2023-02-02T01:53:54Z","timestamp":1675302834000},"page":"1167","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Does the Pathologic Fracture Predict Severe Paralysis in Patients with Metastatic Epidural Spinal Cord Compression (MESCC)?\u2014A Retrospective, Single-Center Cohort Analysis"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5841-7621","authenticated-orcid":false,"given":"Lukas","family":"Klein","sequence":"first","affiliation":[{"name":"Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georg W.","family":"Herget","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"},{"name":"Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8091-1589","authenticated-orcid":false,"given":"Gabriele","family":"Ihorst","sequence":"additional","affiliation":[{"name":"Clinical Trials Unit, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0685-1909","authenticated-orcid":false,"given":"Gernot","family":"Lang","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8801-2385","authenticated-orcid":false,"given":"Hagen","family":"Schmal","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulrich","family":"Hubbe","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Faculty of Medicine, Medical Center\u2014University of Freiburg, 79106 Freiburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/s12957-021-02169-7","article-title":"Clinicopathologic characteristics, metastasis-free survival, and skeletal-related events in 628 patients with skeletal metastases in a tertiary orthopedic and trauma center","volume":"19","author":"Herget","year":"2021","journal-title":"World J. Surg. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1016\/S1474-4422(08)70089-9","article-title":"Metastatic epidural spinal cord compression","volume":"7","author":"Cole","year":"2008","journal-title":"Lancet Neurol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1016\/S1470-2045(05)70022-X","article-title":"Malignant spinal-cord compression","volume":"6","author":"Prasad","year":"2005","journal-title":"Lancet Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta17420","article-title":"A systematic review of evidence on malignant spinal metastases: Natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression","volume":"17","author":"Sutcliffe","year":"2013","journal-title":"Health Technol. Assess."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/S0140-6736(05)66954-1","article-title":"Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial","volume":"366","author":"Patchell","year":"2005","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1111\/iju.13170","article-title":"Skeletal complications in cancer patients with bone metastases","volume":"23","author":"Tsuzuki","year":"2016","journal-title":"Int. J. Urol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1227\/01.NEU.0000349919.31636.05","article-title":"Vertebral Compression Fractures in Patients Presenting with Metastatic Epidural Spinal Cord Compression","volume":"65","author":"Chaichana","year":"2009","journal-title":"Neurosurgery"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"962797","DOI":"10.3389\/fradi.2022.962797","article-title":"Imaging of metastatic epidural spinal cord compression","volume":"2","author":"Bai","year":"2022","journal-title":"Front. Radiol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1215\/S1152851704000262","article-title":"A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease","volume":"7","author":"Klimo","year":"2005","journal-title":"Neuro-Oncology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1038\/ncpneuro0116","article-title":"Surgery Insight: Current management of epidural spinal cord compression from metastatic spine disease","volume":"2","author":"Witham","year":"2006","journal-title":"Nat. Clin. Pract. Neurol."},{"key":"ref_11","unstructured":"(2022, December 01). Delegates AH of ASA Physical Status Classification System. Available online: https:\/\/www.asahq.org\/standards-and-guidelines\/asa-physical-status-classification-system."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"E1221","DOI":"10.1097\/BRS.0b013e3181e16ae2","article-title":"A Novel Classification System for Spinal Instability in Neoplastic Disease","volume":"35","author":"Fisher","year":"2010","journal-title":"Spine"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1097\/00007632-199702010-00002","article-title":"Risk Factors and Probability of Vertebral Body Collapse in Metastases of the Thoracic and Lumbar Spine","volume":"22","author":"Taneichi","year":"1997","journal-title":"Spine"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"324","DOI":"10.3171\/2010.3.SPINE09459","article-title":"Reliability analysis of the epidural spinal cord compression scale","volume":"13","author":"Bilsky","year":"2010","journal-title":"J. Neurosurg. Spine"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Roberts, T.T., Leonard, G.R., and Cepela, D.J. (2017). Classifications in Brief: American Spinal Injury Association (ASIA) Impairment Scale. Clinical Orthopaedics and Related Research, Springer.","DOI":"10.1007\/s11999-016-5133-4"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e016022","DOI":"10.1136\/bmjopen-2017-016022","article-title":"Survival after bone metastasis by primary cancer type: A Danish population-based cohort study","volume":"7","author":"Svensson","year":"2017","journal-title":"BMJ Open"},{"key":"ref_17","unstructured":"Institut, R.K. (2020). Krebs in Deutschland f\u00fcr 2015\/2016, RKI."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Hernandez, R.K., Wade, S.W., Reich, A., Pirolli, M., Liede, A., and Lyman, G.H. (2018). Incidence of bone metastases in patients with solid tumors: Analysis of oncology electronic medical records in the United States. BMC Cancer, 18.","DOI":"10.1186\/s12885-017-3922-0"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"452","DOI":"10.1212\/WNL.49.2.452","article-title":"Spinal epidural metastasis as the initial manifestation of malignancy: Clinical features and diagnostic approach","volume":"49","author":"Schiff","year":"1997","journal-title":"Neurology"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1007\/BF01402610","article-title":"Metastatic spinal cord compression","volume":"107","author":"Bach","year":"1990","journal-title":"Acta Neurochir."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1080\/10428194.2020.1849681","article-title":"Interdisciplinary approach to multiple myeloma\u2014Time to diagnosis and warning signs","volume":"62","author":"Herget","year":"2020","journal-title":"Leuk. Lymphoma"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"E448","DOI":"10.1097\/BRS.0000000000002378","article-title":"Analysis of the Relationship Between the Epidural Spinal Cord Compression (ESCC) Scale and Paralysis Caused by Metastatic Spine Tumors","volume":"43","author":"Uei","year":"2018","journal-title":"Spine"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1053\/clon.2001.0054","article-title":"Spinal Cord Compression\u2014What are the Treatment Standards?","volume":"14","author":"Hardy","year":"2002","journal-title":"Clin. Oncol."},{"key":"ref_24","first-page":"CD006716","article-title":"Interventions for the treatment of metastatic extradural spinal cord compression in adults","volume":"2018","author":"George","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1227\/01.neu.0000317317.33365.15","article-title":"Predictors of Ambulatory Function After Decompressive Surgery for Metastatic Epidural Spinal Cord Compression","volume":"62","author":"Chaichana","year":"2008","journal-title":"Neurosurgery"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"828","DOI":"10.1097\/BRS.0000000000003907","article-title":"Thirty- and 90-day Readmissions After Spinal Surgery for Spine Metastases: A National Trend Analysis of 4423 Patients","volume":"46","author":"Elsamadicy","year":"2020","journal-title":"Spine"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"262","DOI":"10.5312\/wjo.v5.i3.262","article-title":"Scoring system for prediction of metastatic spine tumor prognosis","volume":"5","author":"Tokuhashi","year":"2014","journal-title":"World J. Orthop."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1097\/00007632-200102010-00016","article-title":"Surgical Strategy for Spinal Metastases","volume":"26","author":"Tomita","year":"2001","journal-title":"Spine"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"143","DOI":"10.3109\/17453679508995508","article-title":"Survival after surgery for spinal and extremity metastases: Prognostication in 241 patients","volume":"66","author":"Bauer","year":"2009","journal-title":"Acta Orthop. Scand."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1002\/cncr.20756","article-title":"Prediction of survival in patients with metastases in the spinal column","volume":"103","author":"Linden","year":"2005","journal-title":"Cancer"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1002\/cncr.23150","article-title":"The first score predicting overall survival in patients with metastatic spinal cord compression","volume":"112","author":"Rades","year":"2008","journal-title":"Cancer"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1302\/0301-620X.87B5.15185","article-title":"Prognostic factors and a scoring system for patients with skeletal metastasis","volume":"87","author":"Katagiri","year":"2005","journal-title":"Bone Jt. 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