Saeda Haj

Background and Objectives: The recently published Spine Stereotactic Radiosurgery (SSRS) ESTRO guidelines advise against treating spinal metastatic disease with a single dose equal to or smaller than 18 Gy, prioritizing local control over the potential for complications. This study aims to assess the necessity and validity of these higher dose recommendations by evaluating the outcomes and experiences with lower radiation doses. Materials and Methods: A retrospective evaluation of SSRS patients treated at a single institute was conducted. The outcomes and complications of this cohort were compared to the current literature and the data supporting the new ESTRO guidelines. Results: A total of 149 treatment sessions involving 242 spinal levels were evaluated. The overall local control rate was 91.2%. The mean radiation dose for the local control group compared to the local failure group was similar (17.5 vs. 17.6 Gy, not significant). The overall complication rate was 6%. These results are consistent with previous publications evaluating SSRS for metastatic spinal disease. Conclusions: SSRS dose escalation may increase local control efficacy but comes with a higher risk of complications. The evidence supporting the strong recommendations in the recent ESTRO guidelines is not robust enough to justify a universal application. Given the palliative nature of treatment for metastatic patients, dose determination should be individualized based on patient conditions and preferences, with a detailed discussion about the risk–benefit ratio of increased doses and the level of evidence supporting these recommendations.

Background: Vertebral compression fractures (VCFs) are prevalent in the elderly population and might be the source of back pain if they are fresh and yet unhealed. In many cases, it is a diagnostic challenge to differentiate fresh VCFs from healed united fractures, which retain similar radiographic characteristics but no longer generate pain. This information is crucial for appropriate management. The aim of this study was to evaluate the role of bone scintigraphy (BS) in identifying fresh VCFs appropriate for targeted treatment when compared to the findings of Computerized Tomography (CT). Methods: We retrospectively reviewed 190 patients with back pain suspected to stem from a recent VCF that underwent both a CT and a BS and compared the imaging patterns per vertebra. Results: The studies were concordant in the majority of cases (95.5%), diagnosing 84.4% normal vertebrae, 6.4% acute VCFs, and 4.7% chronic VCFs. However, in 37 patients, 45 occult acute VCFs were only detected on BS and not on CT. Multivariate logistic regression analysis revealed that these patients were older and had lower bone density compared to the rest of the study population. Additionally, 40 patients had acute VCFs visible on CT, but with no increased or low intensity uptake on BS. These cases were associated with a shorter time period between trauma and BS, a higher prevalence of male patients, and a higher bone density. Acute VCFs with no increased uptake or low levels of uptake were found only within the first six days of the trauma. Conclusions: BS detects radiologically occult fractures and can differentiate if a radiographically evident VCF is indeed clinically active, guiding possible treatment options. To avoid missing acute VCFs, BS should be performed six days or more after the injury.